War on Gaza
Trauma, grief, and PTSD in Palestinian children victims of War on Gaza
* Thabet, A, A, MD, PhD
Consultant Child and Adolescent Psychiatrist
Abu Tawahina, A, PhD
Clinical Psychologist
El Sarraj, E, MD
Psychiatrist
Gaza Community Mental Health Programme
Panos Vostanis
Professor of Child and Adolescent Psychiatry, University of Leicester, Greenwood Institute of Child Health, Westcotes House, Westcotes Drive, Leicester LE2 OQU, UK
Tel 0116 2252885; Fax: 0116 2252881; E-mail: pv11@le.ac.uk
* Correspondence
Abstract
Purpose: Exposure to war trauma has been independently associated with posttraumatic stress (PTSD) and grief in children and adults. The aim of this study was to establish the relationship between war traumatic experiences due to last war on Gaza, PTSD, and traumatic grief children.
Methods: The study was conducted in the Gaza Strip, in areas exposed to war for 23 days The sample included 374 children aged 6-17 years. Children completed measures of experience of traumatic events (Gaza Traumatic Checklist-War on Gaza), PTSD , and Grief inventory.
Results: Palestinians children experiences variety of traumatic events: 93.9% hear shelling of the area by artillery, 93.9% hear the sonic sounds of the jetfighters, and 69% left home form more safe place, and 24.5% exposed to burn by bombs. Each child reported 12.80 traumatic events. Results showed that 98.7% of children reported that they were not safe at homes, 96.3% were not able to protect themselves, 96% were not able to protect their family members, and 94.4% said other people outside the family were not able to protect them. The study showed that from total number of children 35 of the children said that they lost someone from the family (9.4%) and 338 said they did not loss any one (90.6%). Mean grief reactions in boys were 19.96 and 18.29 in girls. Using the previous cut-off point of CPTSD-RI , 1.3% of children showed no PTS reactions, 7.2% reported mild PTSD reactions, 29.9% showed moderate PTS reactions, and 61.5% showed severe to very severe PTS reactions. Trauma exposure was significantly associated with PTS reactions. No sex differences in reporting trauma or PTS reactions.
Conclusions: This study revealed that children living in area of conflict and war are the main scapegoats of such war and their exposure to trauma is inevitable during the war and the international laws to protect the civilians during the conflict and establishing save haven for children and their families to decrease the effect of war on children. Also, more interventions must be conducted in group base and concentrated on helping children to overcome their trauma and grief. Also, parents had to be involved in such activities to be able of detecting children with pathological grief and enable them of helping children in overcoming the effect of grief and trauma.
Exposure to war on Gaza trauma and
Key words: War on Gaza, trauma, traumatic grief, child, PTS reactions
Introduction
On 27 December, the Israeli occupying forces conducted sudden and intensive air strikes on Gaza Strip. The attacks began at approximately 11:30 am and lasted for approximately three hours. These attacks destroyed most of the Gaza security offices including police stations. As a result, more than 230 Palestinians were killed and at least 770 we re injured including 100 in critical condition.. This military operation continued for 23 days. As a result, 1320 Palestinians, including 446 children and 110 women and 108 elderly, were killed and 5320 others, including 1855 children and 795 women, were injured. This doesn’t mean that the rest of the fatalities and injuries were engaged in hostilities, or that they are not innocent civilians. A large number of men and male youth were killed in their homes, in the presence of their families. Its phases resulted in a mass destruction of private properties. At least 4000 houses were totally destroyed and other 16000 houses were partially damaged (Humanitarian Duty Report, 2008).
Research evidence is strong about the exposure to political and military violence associating with children’s psychological disorders, including anxiety, psychosomatic, and depression symptoms (Goenjian et al., 2001, 1995; Husain et al., 1998). Majority of the research evidence on child mental health in war is not from acute stage of trauma, and our research attempts to contribute to this lack. We assessed children’s PTSD and grief symptoms two weeks after the massive Israeli bombardment and destruction of Gaza Strip. Earlier research on Palestinian children show that they suffered from substantially high levels of PTSD and other psychological problems even before the War on Gaza. Qouta, Punamaki, and Sarraj (2003) studied the prevalence of PTSD among children living in Gaza who had lost their homes. More than half (53.7%) were suffering from severe PTSD symptoms, and a third (35.5%) from moderate levels of PTSD. Lavi and Solomon (2005) compared Palestinian youngsters living in the Palestinian Authority with their Palestinian counterparts residing in Israel. Among the former, 27.1 per cent reported severe posttraumatic symptoms while 16.9 per cent of those residing in Israel reported correspondingly severe symptoms.
Also Palestinian children and adolescent's exposure to military violence and human losses were common during the siege and military occupation. Thabet et al (2008a) found in a multi-informaton study (N=197 children and 200 parents) that 70% of children in Gaza were likely to present with PTSD and 34% had anxiety symptoms of likely clinical significance, as based on child report. Further 43% of children were rated as having significant mental health morbidity by their parents. The Gaza Palestinian children had experienced a mean number of 8 traumatic events, such as watching mutilated bodies and wounded people on TV (98.5%), witnessing signs of shelling on the ground (94.9%), and hearing shelling of the area by artillery (92.9%) .
Pat-Horenczyk et al (2008) in her study of the effects of the ongoing violence on the mental health of Palestinian and Israeli youths during the spring of 2004 and involved 1235 Palestinian and 1061 Israeli adolescents. The study showed that more than half (57.8%) of the Palestinian students (714 adolescents) reported very severe exposure to political violence, 516 (41.8%) reported moderate to severe exposure, and only five adolescents (1%) reported no exposure to political violence beyond media coverage. Boys were significantly more likely than girls to report experiences of very severe exposure, reported moderate to severe exposure. 37.2% of students reported symptoms meeting the criteria for full PTSD. An additional 150 (12.1%) reported symptoms meeting the criteria for partial PTSD (i.e. exposure, functional impairment, and two out of the three clusters of re-experiencing, avoidance, and hyperarousal). Girls reported more somatic complaints than boys. There also was a main effect for gender, indicating that girls reported more severe PTS than boys. Also, students who reported very severe exposure also reported more functional impairment than students who reported moderate to severe exposure. Abdeen et al (2008) 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 The results showed that nearly all (99%) of participants reported some type of direct exposure to political violence during Al Aqsa Intifada. Exposure to war-like events.(WBG = West Bank and Gaza Strip); WB = West Bank; GS = Gaza Strip). Nearly all (99%) of participants reported some type of direct exposure to violence. Reports of high exposure were: WBG = 26%; WB = 28%; GS = 21%. Reports of medium exposure were: WB = 45%; GS = 37%. Reports of low exposure were: WBG = 32%; WB = 27%; GS = 40%. Boys reported higher exposure than girls (67% vs. 33%), (2(1, N = 2100) = 142.9, p < .001. However, more girls than boys reported medium (58% vs. 40%), (2(1, N = 2100) = 5.87, p = .015 and low exposure (68% vs. 32%), (2(1, N = 2100) = 73.09, p = .015.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. Boys reported more direct exposure whereas girls reported more witnessing. In another study of the impact of siege on Palestinian children mental health and resilience (Thabet et al, 2009a in press) , a sample of 386 children was selected from a community pole from the entire Gaza Strip. The study showed that Palestinian children exposed to mean of 10.18 events due to Israeli aggression and 7.42 events due to factional fighting. No gender differences in reported traumatic events. Posttraumatic stress symptoms mean was 25.94, re-experiencing symptoms mean was 7.50, avoidance symptoms mean was 8.21, and arousal symptoms mean was 7.65. Forty eight children reported probable PTSD (12.4%), 26.7% children were reported one criteria (reexperiencing, or avoidance, or hyperarousal), 22.3% of children reported two criteria-Partial PTSD, and 38.4% of chidren had no PTSD symptoms. No gender differences in PTSD.
Bereavement is defined as the objective experience of having a loved one die. Thus, bereavement is a ubiquitous event experienced by almost everyone. Grief is considered the reaction to bereavement. Grief is defined as the emotional, physiological, cognitive, and behavioral reactions to the death of someone significant, often has serious consequences for children . They may experience developmental delays as well as long-term psychiatric, social, and psychological struggles (Stroebe, Hansson, Stroebe, & Schut, 2002). Recent research focusing on the interaction between trauma and grief symptoms (e.g., Eth & Pynoos, 1994; Nader , Pynoos, Fairbanks, & Frederick, 1990; Nader et al, 1993; Layne, Aisenberg, & Pynoos, 2001). Childhood traumatic grief is a relatively new construct, conceptualized as distinct from uncomplicated grief, depression, and posttraumatic stress disorder (PTSD), in which a child has lost a loved one through circumstances that are “objectively or subjectively traumatic,” and in which trauma symptoms interfere with the normal grieving process (Cohen & Mannarino, 2004). Pfefferbaum et al (2006) in study of trauma, grief and depression in Nairobi children after the 1998 bombing of the American Embassy found was no significant interaction of post-bomb loss and bomb-related posttraumatic stress in predicting grief, indicating that the relationship of bomb-related posttraumatic stress with grief did not differ for those losing someone after the bombing compared to those who did not lose anyone after the bombing. There was also no significant interaction of bomb-related loss and bomb-related PTSS in predicting grief, suggesting that the relationship of bomb-related posttraumatic stress with grief was the same for those losing family members or relatives as for those losing friends or acquaintances.
The aim of the study was to investigate the impact of war traumatic experiences on children grief, PTSD.
Methods
Setting and Sample
The Gaza Strip is a narrow elongated piece of land, bordering the Mediterranean Sea between Israel and Egypt, and covers 360 km2. 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 is high unemployment, socioeconomic deprivation, family overcrowding, and short life expectancy. Nearly two-thirds of the populations are refugees, with approximately 55% living in eight crowded refugee camps. The remainder lives in villages and towns. Since September 2005, the population of the Gaza Strip has been exposed to regular incursions and shelling, resulting in at least 200 deaths and many more injuries, in the last six months alone.
The study population included 374 children living in areas exposed to 23 days of shelling, incursion, and bombardment, in the entire Gaza Strip. The total sample was selected using EPI 6 in which the total sample was 380 children. We added 20 children to the sample for missing interviews. Children were selected from families randomly from the five areas of the Gaza Strip. One street was selected in each area, and every third household that fulfilled the selection criteria. In larger buildings, one flat from each floor was selected.
The data collection was carried out by 8 trained professionals, under the supervision of the first author. The data was collected during Feb 2008. Children were interviewed in their homes after getting written consent from parents to participate in the study. One of the difficulties of this study was that, throughout the interviews, there was strong feelings of hostility, anger, and intolerance to interview in the selected areas, for which reason the interviews had to be discontinued with some children and to be repeated later on.
Measures
· Demographic questionnaire.
Demographic information about the participants was obtained using a survey developed by the authors. This questionnaire includes sex, age, number of children, and education level.
· Traumatic events were assessed by checklists that reflected the nature of violence, trauma and losses during the war on Gaza. Israeli military violence was assessed by the Gaza Traumatic Events Checklist for Israeli Violence (Thabet, Abdulla, El Helou, & Vostanis, 2006) consisting of 30 items covering three domains of events typical for the Israeli siege: (1) witnessing personally acts of violence (e.g., killing of relatives, home demolition, bombardment, and injuries), (2) having experiences of loss, injury and destruction in family and other close persons, and (3) being personally the target of violence (e.g., being shot, injured, or beaten by the soldiers). In checklist children were asked whether they had been exposed to each of these events: (0) no, (1) yes during the 23 days of war.
· Grief screening Scale (GSS; Layne, Steinberg, Savjak, & Pynoos, 1998)
The GSS is a 10- item self-report screening inventory of grief symptoms in adolescents and adults. The scale is a revised version of The UCLA Grief Inventory (Pynoos, Nader,
Frederick & Gonda, 1987) and is composed to two factor-analytically derived subscales containing five items each: One subscale measures symptoms of normal grief, and the other measures symptoms of complicated grief. Symptoms experienced during the past 4 weeks are measures on a 5 point Likert-type frequency scale consisting of 0 = never, 1 = rarely, 2 = sometimes, 3 = often, 4 = almost always. Layne et al. (2006) reported a full-scale Cronbach’s alpha of .86 and good convergent validity. In this study Cronbach’s alpha is 0.83.
· Children’s Post Traumatic Stress Reaction Index (CPTSD-RI)This standardised 20-item self-report measure was designed to assess post-traumatic stress reactions of children aged 6-16 years following exposure to a broad range of traumatic events (Pynoos et al, 1987). It includes three subscales, Intrusion (7 items), Avoidance (5 items) and Arousal (5 items), and three additional items. The scale has been found valid in detecting the likelihood of PTSD. Items are rated on a 0-4 scale, and the range of total CPTSD-RI scores is between 0-80. Scores are classified as ‘mild PTSD reaction’ (total score 12-24), ‘moderate’ (25-39), ‘severe’ (40-59), and ‘very severe reaction’ (above 60). The CPTSD-RI used in this study was based on DSM-IIIR criteria, rather than another PTSD instrument based on DSM-IV criteria, as the CPTSD-RI had already been validated in the Arab culture (Thabet & Vostanis, 1999, 2004).
Statistics analyses
Cross tables with Pearson c2 –statistics were applied to analyse the associations between demographic factors, trauma, grief, and PTSD, and gender differences in exposure to traumatic events, grief, and PTSD. T- independent tests were applied to analyse gender differences in trauma, grief, and PTSD. To analyse the predictive role of traumatic experiences by children, grief, and PTSD, we used hhierarchical multiple regression analyses with main and interaction effects. The estimated main effects indicate direct associations between trauma and PTSD. The dependent variables were PTSD and grief and independent variables were 30 traumatic experiences. In the Step I, demographic factors were entered, in the Step II, the traumatic events (Israeli military violence in the last war on Gaza) were entered.
Results
Sociodemographic characteristics of study population (N = 374)
The sample consisted of 374 children, 197 were males (52.7%) and 177 were females 47.3%. The age ranged from 6 to 17 years with mean age 11.09 (SD = 2.9). According to place of residence, 34.2% were from North Gaza, 24.9% were from Gaza city, 15.8% were from middle area, 7.8% from Khan Younis, and 17.4% were from Rafah area. According to type of living, 44% live in cities, 20.9% live in villages, and 34.8% live in refugee camps. According to family monthly income, 60.9% had less than 300 US $ monthly, 26.% had 301-650 $ monthly, and 13.1% had 651 and above
Table 1
Sociodemographic characteristics of study population (N = 374)
|
|
N |
% |
|
1. Sex |
|
|
|
Male |
197 |
52.7 |
|
Female |
177 |
47.3 |
|
Mean = 11.09 years (SD = 7.48) |
|
|
|
3. Place of residence |
|
|
|
North Gaza |
128 |
34.2 |
|
Gaza |
93 |
24.9 |
|
Middle area |
59 |
15.8 |
|
Khan Younis |
29 |
7.8 |
|
Rafah area |
65 |
17.4 |
|
4. Type of residence |
|
|
|
City |
166 |
44.4 |
|
Village |
78 |
20.9 |
|
Camp |
130 |
34.8 |
|
No of siblings |
|
|
|
Less than 4 |
99 |
26.5 |
|
5-7 siblings |
172 |
46.0 |
|
8 and more |
103 |
27.5 |
|
Family monthly income |
|
|
|
Less than 300 US $ |
190 |
60.9 |
|
301-650 $ |
81 |
26.0 |
|
651$ and more |
41 |
13.1 |
|
Father job |
|
|
|
Unemployed |
109 |
36.8 |
|
Simple worker |
54 |
18.2 |
|
Skilled worker |
39 |
13.2 |
|
Employee |
72 |
24.3 |
|
Merchant |
11 |
3.7 |
|
Others |
11 |
3.7 |
|
Mother job |
|
|
|
Housewife |
296 |
90.2 |
|
Simple worker |
10 |
3.0 |
|
Employee |
12 |
3.7 |
|
Others |
10 |
3.0 |
Types of traumatic events
Palestinians children experiences variety of traumatic events: 93.9% hear shelling of the area by artillery, 93.9% hear the sonic sounds of the jetfighters, 91.4% witnessing the signs of shelling on the ground, 94.9% watched mutilated bodies in TV, 73% were deprived from water or electricity during the war, 69% said they left home form more safe place.
Table 2
The most common traumatic events
|
Types of traumatic events |
No. |
% |
|
3. Hearing shelling of the area by artillery |
351 |
93.9 |
|
4. Hearing the sonic sounds of the jetfighters |
351 |
93.9 |
|
16. Witnessing the signs of shelling on the ground |
342 |
91.4 |
|
14. Watching mutilated bodies in TV |
335 |
94.9 |
|
21. Deprivation from water or electricity during detention at home |
273 |
73 |
|
30. Forced to leave your home during the war |
258 |
69 |
|
12. Witnessing firing by tanks and heavy artillery at neighbours homes |
239 |
63.9 |
|
11. Witnessing of a friend home demolition |
225 |
60.2 |
|
15. Witnessing assassination of people by rockets |
203 |
54.3 |
|
19. Being detained at home during incursion |
198 |
52.9 |
|
1. Hearing killing of a friend |
177 |
47.3 |
|
2. Hearing killing of a close relative |
167 |
44.7 |
|
5. Hearing of arrest of someone or a friend |
157 |
42 |
|
22. Threaten by shooting |
150 |
40.1 |
|
23. Destroying of your personal belongings during incursion |
133 |
35.6 |
|
13. Witnessing firing by tanks and heavy artillery at own home |
127 |
34 |
|
10. Witnessing of own home destruction |
124 |
32.2 |
|
27. Deprivation from going to toilet and leave the room at home where you was detained |
101 |
27 |
|
8. Witnessing shooting of a friend |
89 |
23.8 |
|
6. Witnessing killing of a friend |
86 |
23 |
|
9. Witnessing shooting of a close relative |
85 |
22.7 |
|
28. Exposure to burn by bombs and phosphorous bombs |
84 |
22.5 |
|
7. Witnessing killing of a close relative |
81 |
21.7 |
|
20. Beating and humiliation by the army |
72 |
19.3 |
|
25. Threaten of family member of being killed |
69 |
18.4 |
|
17. Shooting by bullets, rocket, or bombs |
61 |
16.3 |
|
24. Threaten of being killed |
61 |
16.3 |
|
18. Physical injury due to bombardment of your home |
58 |
15.5 |
|
26. Threatened to death by being used as human shield to arrest your neighbors by the army |
54 |
14.4 |
|
29. Being arrested during the last incursion |
49 |
13.1 |
Sex differences in traumatic events
Children reported from no events to 30 traumatic events, mean traumatic events was 12.80 (SD = 6.56). The results showed that mean traumatic events reported by males was 12.03 (SD =6.46) compared to mean in female =12.50 (SD = 6.64). No significant differences between males and females in reporting traumatic events (t=0.78, p = 0.44).
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 = 0.11, p = 0.001).
Safety during the war on Gaza
On asking the children about their safety at homes and being protected by adults, the results showed that 98.7% of children reported that they were not safe at homes, 96.3% were not able to protect themselves, 96% were not able to protect their family members, and 94.4% said other people outside the family were not able to protect them.
Table 3
Safety during the war on Gaza
|
|
|
No |
Yes |
|
1 |
They were safe at homes |
98.7 |
1.3 |
|
2 |
Able to protect themselves |
96.3 |
3.7 |
|
3 |
Able to protect their family members |
96.0 |
4.0 |
|
4 |
People outside the family were able to protect them |
94.4 |
5.6 |
Loss of someone from the family
The study showed that from total number of children 35 of the children said that they lost someone from the family (9.4%) and 338 said they did not loss any one (90.6%).
Figure 1
Loss of someone from the family
Grief reactions in children due to loss
Unpleasant thoughts (bad or upsetting thoughts) about how the person died get in the way of enjoying good memories of him/her.The results showed that 51.4% were enjoying good memories of lost person, 51.4% had unpleasant thoughts (bad or upsetting thoughts) about how the person died get in the way of enjoying good memories of him/her.
Table 4
Grief reactions in children due to loss
|
Grief reactions |
Never |
Rarely
|
Sometimes
|
Often
|
Almost Always
|
|
5.7 |
5.7 |
25.7 |
11.4 |
51.4 |
|
17.1 |
22.9 |
34.3 |
2.9 |
22.9 |
|
11.4 |
22.9 |
25.7 |
14.3 |
25.7 |
|
8.6 |
11.4 |
17.1 |
11.4 |
51.4 |
|
31.4 |
14.3 |
22.9 |
14.3 |
17.1 |
|
51.4 |
17.1 |
11.4 |
5.7 |
14.3 |
|
20 |
5.7 |
48.6 |
8.6 |
17.1 |
|
57.1 |
14.3 |
14.3 |
5.7 |
8.6 |
|
20 |
20 |
22.9 |
2.9 |
34.3 |
|
17.1 |
11.4 |
31.4 |
17.1 |
22.9 |
Sex differences in traumatic grief subscale
Create summative scores for the traumatic grief subscale by adding up the responses to the 10 grief items, mean grief in boys was 19.96 (SD= 8.89), and 18.29 (SD =9.81) in girls. The results showed no significant differences between boys and girls in reporting traumatic grief items (t=1.21, p = 0.22).
Univariate linear regression analysis was carried out in which total grief was dependent variable and each traumatic event as independent variable. The results showed that the following traumatic events were predicting the traumatic grief in children: witnessing killing of close relative (B=5.64, p=0.001) and witnessing assassination of people by rockets (B=2.66, p=0.04) (F = 12.22 p <0.05, R2=0.11).
Post traumatic stress reactions
Psychological reactions to trauma of war (CPTSD-RI)
Children report variety of psychological reactions, 86.1% identifies event as extreme stressor, 64.4% said they get scared, afraid or upset when they think about the war time, 63.1% had intrusive images and sounds of the war, and 61.2% had fear of recurrence of the war on Gaza after reminders.
Table 5
Psychological reactions to trauma of war (CPTSD-RI)
|
|
No/rarely |
Sometimes |
Most/much |
|
1. Identifies event as extreme stressor |
5.6 |
8.3 |
86.1 |
|
2. Afraid when thinks about event |
12.9 |
22.7 |
64.4 |
|
3. Intrusive images and sounds |
15.8 |
21.1 |
63.1 |
|
6. Fear of recurrence after reminders |
16.6 |
22.2 |
61.2 |
|
4. Intrusive thoughts |
16.9 |
29.7 |
53.5 |
|
17. Upset when thinks about event |
21.9 |
28.1 |
50 |
|
7. Loss of interest in significant activities |
25.7 |
26.2 |
48.1 |
|
11. Jumpy/nervous/startle easily |
35.2 |
27.3 |
37.5 |
|
16. Avoidance of reminders |
29.4 |
33.2 |
37.4 |
|
5. Bad dreams |
33.1 |
31.8 |
35.1 |
|
9. Wish to avoid feelings |
34.5 |
31 |
34.5 |
|
10. Constricted affect |
35.6 |
34.2 |
30.2 |
|
14. Thoughts of event interfere with learning |
31.2 |
39.3 |
29.5 |
|
18. Experiencing reminders of event |
45.6 |
26.5 |
27.9 |
|
13. Guilt |
44.9 |
28.1 |
27 |
|
8. Estrangement(interpersonal distance) |
37.7 |
35.3 |
27 |
|
19. Somatic complaints |
53.2 |
23.3 |
23.5 |
|
20. Problems with impulse control |
56.2 |
21.4 |
22.4 |
|
15. Difficulty concentrating |
53.5 |
27.8 |
18.7 |
|
12. Sleep disturbance |
46.8 |
35.3 |
17.9 |
Post traumatic stress reactions (CPTSD-RI)
The results showed that mean PTS reactions was 41.4 (SD =11.7), intrusion symptoms mean was 16.04, avoidance mean was 9.25, and hyperarousal mean was 10.2. In order to find the differences in PTS reactions according to sex, t independent test was done. The results showed that there was no significant difference between boys and girls in total PTS reactions and other subscale (t=0.53. p = ns). Also, no differences in PTS reactions between younger age and older age children (6-12, 13 and above).
Table 6
Differences in means of CPTSD-RI, intrusion symptoms, avoidance, and hyperarousal Sex differences in PTS reactions
CPTSD-RI |
Male (N = 197) |
Female (N= 177) |
t
|
||
|
Mean |
SD |
Mean |
SD |
||
|
Total PST reactions |
41.8 |
11.9 |
41.2 |
11.7 |
//0.53 |
|
Intrusion symptoms |
16.4 |
4.9 |
15.7 |
5.4 |
//1.32 |
|
Avoidance symptoms |
9.1 |
4.0 |
9.4 |
3.6 |
//-0.63 |
|
Hyperarousal symptoms |
10.3 |
3.5 |
10.1 |
3.5 |
//0.60 |
**p<0.01 *p <0.05 //p>0.05
Prevalence of PTS reactions
Using the previous cut-off point of CPTSD-RI , 1.3% of children showed no PTS reactions, 7.2% reported mild PTS reactions, 29.9% showed moderate PTS reactions, and 61.5% showed severe to very severe PTSD reactions. Chi square test showed no significant sex differences in reporting PTS reactions (c2 = 0.342, df = 3, p <0.95).
Table 7
Prevalence of PTSD
|
|
No PTS reactions |
Mild reaction |
Moderate |
Severe/very severe |
Total |
|
Male |
2 |
14 |
59 |
122 |
197 |
|
0.5% |
3.7% |
15.8% |
32.6% |
52.7% |
|
|
Female |
3 |
13 |
53 |
108 |
177 |
|
0.8% |
3.5% |
14.2% |
28.9% |
47.3% |
|
|
Total |
5 |
27 |
112 |
230 |
374 |
|
1.3% |
7.2% |
29.9% |
61.5% |
100.0% |
In order to find the differences between different sociodemographic variables such as place of residence, type of residence, family monthly income, number of siblings and PTS reactions, One way ANOVA was done in which PTS reactions, intrusion symptoms , avoidance, and hyperarousal were entered as dependent variables and sociodemographic variables as independent variables. The results showed no significant differences in PTS reactions, intrusion symptoms, avoidance, and hyperarousal and other sociodeographic variables except being living with family was significantly exposed the children to have more intrusion symptoms than those children living in their own homes or in rented places (F = 3.21, p = .023)
In a univariate linear regression analysis, each traumatic event was entered as an independent variable in a multiple regression model, with total PTS reactions scores as the dependent variable, five events were significantly associated with PTS reactions symptoms:threaten by shooting: (B=4.47, p=0.001); forced to leave home during the war: B=3.25, p=0.012, witnessing killing of a friend (B= -4.912, p=0.001), witnessing of a friend home demolition: (B=3.284, p=0.01), and hearing killing of a close relative (B=2.474, p=0.001) (F = 9.03 p <0.05, R2=0.10).
In another univariate linear regression analysis, each grief reaction was entered as an independent variable in a multiple regression model, with total PTS reactions scores: I have upsetting or scary dreams about the person who died (B=3.513, p=0.001), and I think about getting revenge on whoever is responsible for his/her death (B=1.081, p=0.02) (F = 24.72 p <0.05, R2=0.21).
Discussion
Trauma, posttraumatic stress and grief were examined in Palestinian children and adolescents 2 weeks after experiencing loss and trauma due to War on Gaza. The study showed that children reported commonly direct and indirect types of traumatic event. The finding of this study concurrent with almost all the previous studies in the area, but new traumatic events were characterizing this time which include forced to leave the homes due unsafety and exposure to burn by phosphorus bombs (Thabet et al, 2007, 2008, Abdeen, 2008). The study showed no sex differences in reporting traumatic events and also no age differences. This is inconsistent with previous studies in the area which showed that boys were more traumatized than girls (Thabet et al, 2008, Al Erjani and Thabet, 2008)
This study revealed that there was no safe place for children and families and children were not able to feel safe or believe that someone can protect them which was accumulative stress beside the other traumatic events. This unsafe feelings lead to internal displacement of the families and this item was predicting the PTSD and traumatic grief in children. Loss of close relative, friend, or someone close to the children was one of the traumatic events for children and their families. Almost half of the children said that they lost some one they know and this loss increase the children grief and bereavement.
The results showed that losing some one lead to enjoying good memories of lost person, feel that, even though he/she is gone, he/she is still an important part of his life, think about getting revenge on whoever is responsible for his/her death, uunpleasant thoughts (bad or upsetting thoughts) about how the person died get in the way of enjoying good memories of him/her. These finding different from previously study of Palestinian children in South of Gaza in which the most common grief symptoms were have pleasant or comforting dreams about the person who died, seeing the dead person, crying when remembering him, and denying that he gone (Shaat and Thabet, 2007). Our finding of no sex differences in total grief is consistent with study of children in north Darfur (Morgan, 2008).
Our study consistent with previous studies such as effect if bombardment of Amiria shelter in Iraq (Dyregrov and Raundalen, 1991), Israeli children living in North of Israel (Elizur and Kaffman,1982), and Kuwaiti children exposed to war during invasion of Kuwait (Nader et al, 1993).
However children who lost someone were not different in reporting grief, PTSD, intrusion symptoms, avoidance, and hyperarousal. This could be explained that there was mass trauma and all the shield of protection in children were fallen down and other traumatic events played a role in developing PTSD in children and this was obvious in findings that there was significant association between total traumatic events and PTSD. This is consistent with previous studies in the area (Qouta et al, 2003, Thabet et al, 2004, 2006, 2007, 2008, Al Erjani and Thabet, 2008).
Our study showed that the best traumatic events predicting total grief were witnessing killing of close relative and witnessing assassination of people by rockets, those traumatic events similar to previous study of Darfur children which found that abduction; 2) death of one or more parents; 3) seeing homes burned; 4) witness shooting; and 5) witnessing rape were predicting grief in children (Morgan, 2008).
The study showed the most common psychological reactions were intrusive symptoms such as identifies event as extreme stressor, scared, afraid or upset when they think about the war time, intrusive images and sounds of the war and fear of recurrence of the war on Gaza after reminders. Intrusion symptoms such as fears and nightmares might develop early as an acute response among people being in a continuous state of ‘high alert’, while avoidance symptoms might develop later, or in response to different types of traumatic situations. Previous studies in the area showed that insomnia, exaggerated startle, and trying to remove memories from their mind were more common those other symptoms (Thabet, 2008).
The rate of PTSD symptoms among children was of sufficient severity to require assessment and intervention. The study results showed that mean PTSD was 41, this is lower than the mean PTSD scores in study of children of Darfur in Sudan which showed than mean PTSD was 44.89 (Morgos et al, 2008).
The rate of PTSD was higher that previous studies finding in previous studies (Thabet et al 2000, 2004, 2008 in press, Abdeen et al, 2008, Quota et al, 2003, Pat-Horenczyk et al, 2008) ), and lower that found in children exposed to continuous shelling of the Gaza Strip (Thabet, 2007, 2008). Also this study was consistent with previous studies in the area in which there were no significant difference in PTSD according to sex, age, family monthly income, and place of residence (Thabet et al, 2008). However this level of PTSD is less than that rate found in Darfur children which showed that prevalence of PTSD symptoms found in 75% of the children (Morgan, 2008).
The results of this study showed that specific types of war exposures predicted trauma symptoms. Of the possible war experiences, threaten by shooting, forced to leave home during the war, witnessing killing of a friend, witnessing of a friend home demolition, and hearing killing of a close relative. The separation from one’s family can be particularly traumatic since this separation often results in the loss of primary caregivers, which eliminates a crucial protective factor against stress in times of war. These findings are born out in other studies assessing trauma among war children (Thabet et al., 2004).
This study has a number of limitations. This study was done immediately after the war on Gaza and children and families still under the effect of severe traumatic events which showed that most of the symptoms were due to acute stress and previous traumatic events may play a role in such case. A follow-up study after 3-6 months many may helped understand better the changes in grief and psychopathology among children in relation to changes in trauma exposure.
Conclusion and recommendations
This study revealed that children living in area of conflict and war are the main scapegoats of such war and their exposure to trauma is inevitable during the war and the international laws to protect the civilians during the conflict and establishing save haven for children and their families to decrease the effect of war on children. Also, more interventions must be conducted in group base and concentrated on helping children to overcome their trauma and grief. Also, parents had to be involved in such activities to be able of detecting children with pathological grief and enable them of helping children in overcoming the effect of grief and trauma.
Acknowledgements
We are grateful to the team who collected the data
under enormous difficulties. Also, our many thanks to families and children who
participated in this study, for their openness in sharing such difficult issues.
Also to Khalil Megdad for his work as statistician in this study.
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