The effect of war on
children’s mental health is well established.
Investigators, mainly from
the Middle East and the former Yugoslavia,
have recorded high rates of post-traumatic stress disorders and other mental
health problems and disorders. For example, after the Gulf war, high rates of
post-traumatic stress disorders were recorded in Kuwaiti and Kurdish children.(2,3,4)
These rates were especially prominent in
children who had been displaced from their community, such as in the conflicts
in Croatia, (5) and Bosnia.(6,7,8)
Children who are directly or
indirectly exposed to war conflict experience a variety of stressors, and many
develop both short-term and long-term post-traumatic stress reactions.(9)
Living in a refugee camp
outside home, living under conditions of war, being on the run, witnessing
bombing, changing residence due to war, taking shelter from bombing, witnessing
street shooting, witnessing house search, father detained, separated from
father more than one month, death in the family, father tortured, witnessing
torture, killing or intimidation of other than family members and witnessing
arrest of family member.(10)
In his review, Vernberg (1999) suggests that
children are at greater risk of post traumatic stress disorder (PTSD) than
adolescents because they have not only a more limited understanding of the
surrounding world, but also have fewer coping skills and less opportunity to
participate in community systems that help people cope with the disaster.(11)
No matter how sophisticated
the diagnostic instrument, nothing can replace a thorough, well-conducted
clinical interview. It is essential in the assessment of pediatric PTSD that
clinicians utilize multiple informants and undertake careful histories while
searching for complicating co-morbid conditions. No single instrument will
serve all clinicians.(12)
Gender can be a factor in
how children react to stress of any magnitude. Boys tend to react with more
aggression and acting-out behaviors and girls tend to respond more inwardly,
their sadness and anxiety are less observable.(13)
Diagnostic and Statistical
Manual (DSM) is widely used around the world both for adults and children in
the assessment and diagnosis of PTSD symptoms. DSM IV-TR(14)
defines PTSD into three symptom clusters (i.e., intrusion, avoidance/numbing,
and arousal). In DSM, re-experiencing includes recurrent and intrusive thoughts
about the trauma, dreaming or flashbacks of the traumatic event, and intense
psychological distress caused by internal or external stimuli, which is
symbolized by or associated with the traumatic event.(14, 15)
In children and adolescents,
repetitive plays and re-enactments may be observed.
Avoidance/numbing includes avoidance of conversations,
places, and feelings associated with the traumatic event (in children, there
may/may not be obvious link to the original trauma), amnesia for aspects of the trauma, detachment from others,withdrawal, or decreased interest in usual activities.
Table I. Distribution of referred children by age:
|
Age
|
Number
|
%
|
|
5 -9 years
|
84
|
42.86
|
|
10-14 years
|
112
|
57.14
|
|
Total
|
196
|
100
|
Table II.
Distribution of referred children by gender:
|
Gender
|
Number
|
%
|
|
Male
|
131
|
66.84
|
|
Female
|
65
|
33.16
|
|
Total
|
196
|
100
|
Table III. Distribution of Children with PTSD by age:
|
Age
|
Number
|
%
|
|
5 -9 years
|
76
|
43.93
|
|
10-14 years
|
97
|
56.07
|
|
Total
|
173
|
100
|
Table IV.
Distribution of PTSD children by gender:
|
Gender
|
Number
|
%
|
|
Male
|
111
|
64.16
|
|
Female
|
62
|
35.84
|
|
Total
|
173
|
100
|
Table V. Children aged 5 to 14 years Referred then found to
have PTSD, comparison between genders:
|
PTSD-By age
|
Male
|
Female
|
Male as % of total
|
Female as % of total
|
|
5 years
|
7
|
4
|
4.05
|
2.31
|
|
6 years
|
8
|
5
|
4.62
|
2.89
|
|
7 years
|
12
|
9
|
6.94
|
5.20
|
|
8 years
|
9
|
3
|
5.20
|
1.73
|
|
9 years
|
12
|
7
|
6.94
|
4.05
|
|
10 years
|
11
|
5
|
6.36
|
2.89
|
|
11 years
|
11
|
6
|
6.36
|
3.47
|
|
12 years
|
16
|
9
|
9.25
|
5.20
|
|
13 years
|
12
|
6
|
6.94
|
3.47
|
|
14 years
|
13
|
8
|
7.51
|
4.62
|
|
Total
|
111
|
62
|
64.16
|
35.84
|
In children, this may take
the form of loss of previously acquired developmental skills such as toilet
training.(14, 15, 16)
Increased arousal includes sleep disturbances,
irritability, increased startle response, and concentration problems. In
children, increased arousal may be observed when a child is exposed to
situations associated with the traumatic event.(15,16) Appendix
1(10) summarizes the symptom list of PTSD.
Although the definition of
PTSD in DSM-IV does consider symptomatology in children it is still adult
focused.(17)
Gaza area has been in a state of war for around 60 years.
The background of the present study was the war in Gaza that started in December 2008 with quite
intensive bombing causing loss of lives, homes and other resources. This war
also had a strong influence on the psychological and social functioning of
Palestinians living in the affected area.
Methods
This study was conducted at
the Jordanian field hospital located in Gaza
city, during the period between 26th December 2009 and 25th
February 2010 where data was collected
12 months after the start of the latest war acts in the area.
We included children aged
5-14 years, who were subdivided into two categories; the first 5-9 years and
the second 10-14 years. Participants were from different places in Gaza strip.
Data were collected from the
sample by means of a well structured clinical psychiatric interview with
children and their parents; based on (DSM IV-TR) for PTSD, we used the
interview of the National Center for PTSD from United states
veteran affairs (Appendix 2). History
included details about the trauma and course of the illness.
A total of 196 children were
interviewed.
Results
A total of 827 children
between the ages of 5-14 years, being 425 males (51.39%) and 402 females
(48.61%), visited the pediatric and family medicine clinics at our hospital for
all sorts of medical problems during the study period.
Out of these children, 196
children were referred to the psychiatry clinic with abnormal behavior being
23.7% of the total studied children.
Table I shows the age distribution
of the referred children where those 10-14 years constitutes about 57% of all participants;
these ages were combined into two major groups.
The first group (5-9 years)
was 84 children (42.86%), while the second group (10-14 years) was 112 children
(57.14%) Table I.
The distribution of the
referred children according to gender was 131 males (66.84%) and 65 females
(33.16%) as shown in table II
PTSD was found in 173
children being (20.9%) of the whole study sample and (88.27%) of the referred
children.
Table III presents the PTSD which was found in
76 children (43.93%) of the first age group, and in 97 children (56.07%) of the
second age group. Males formed 64.16% of
cases, and females 35.84% Table IV.
Statistical analysis showed
the average males age to be 9.98 years, and the average females age 9.90 years.
The number of samples,
n1=111, n2=62, variance s1 was 0.66 for males, s2 was 2.81 for females.
Discussion
Our study revealed a high
level of PTSD among children in Gaza,
this is reflected by the fact that (20.9%) of all children visiting our
hospital in the 5-14 years age range suffer from PTSD symptoms.
We could not find data
describing PTSD symptoms included in table 5 in Gaza children prior to December 2008.
This percentage corresponds
with the levels of PTSD in other studies i.e. the Lebanese(18)
study (27%) and the Israeli study (22-25%) (3) but lower than
that reported in other studies like a previous Palestinian study (59%),(19)
a Turkish study (60%),(20) an Iraqi study (84 %),(21)
and an Iranian study.(22) Our percentage was higher than the
Kuwaiti study (4%).(23)
Studies which have high
prevalence rates of PTSD relate this to various factors, including lack of care
and treatment to this age group, lack of social support, and also that the
military threat and aggression is long standing and continuous with sporadic
aggressions from time to time.
These
contributing factors are all existed in Gaza
at the time of the current study.
The difference in percentage
of PTSD in different studies could be due to the difference in the threshold of
tolerance at various parts of the world as well as due to the difference in
severity of the insult causing the psychological trauma.
In previous studies in Gaza
during previous conflicts in years 2003,(24) and 2004(25)
the most common traumatic events reported by Palestinian children were seeing
victims’ pictures on television, and witnessing bombardment and shelling; with
between one-third and half of the children in different samples fulfilling
criteria for PTSD.(24,25) They were also likely to present
with high rates of anxiety or depressive disorders.(25,26)
Another contributing factor
for the problem in Gaza
is the severe social and economic consequences of the war, which includes home
destruction and imprisonment of many family members of the affected homes.
Our observation is that the
majority of children who were found to have PTSD was directly exposed to
military violence due to the fact that they reside in the hottest border fronts
in the north of Gaza
strip, namely Jabalia, Bait Lahia, and Bait Hanoon. Many of these children’s houses
were demolished.
This is in contrast to
children living in non-bombarded areas where symptoms were more likely to be
anticipatory anxiety symptoms.
These results are consistent
with other studies.(19, 27, 28)
We noticed no obvious decline
in the severity and persistence of symptoms in the affected children in spite
of the long period since the latest major military actions, this is probably
due to the still existing military threat, in addition to the seize being
imposed on Gaza, with its financial and social difficulties.
The frequency of PTSD in
children may vary according to gender; most of the studies reported that
females are more liable to develop symptoms of PTSD, for example,(21,29-31)
while in some other studies there were no differences in the occurrence of PTSD
among both genders(19,32,33) but in our study we found that
symptoms of PTSD are more prevalent among males rather than female patients,
similar to other studies.(34, 35)
Our explanation for male
predominance for PTSD in our study is the feeling of the local population of shame
towards bringing a female to hospital, especially to a psychiatry clinic, this
is because of fear of getting the social stigmata of being sick with a
‘psychiatric problem’ which may affect future marriage proposals.
Research shows contradictory
results regarding the association between child’s age and PTSD: some studies
have higher prevalence in younger children(36,37,38) who have
been found to be vulnerable in war situations. While in other studies young
children have been suggested to be protected due to their less accurate
perception and understanding of trauma(39,40) while others
argue that young children are more vulnerable due to their less effective
coping capacities.(36,41)
In our study we found that
the older age group 10-14 years had more frequent PTSD (Table IV).
Children who were less
likely to recover from PTSD symptoms over time were those with exposure to stronger
short-term posttraumatic stress reactions, those with higher eyewitness
exposure to war violence and more use of expressive coping, and less social
support as has been found in a study from Croatia.(42)
The most frequent PTSD symptoms
we encountered in this area were those of lack of concentration causing
academic impairment, suffering from nightmares, getting easily upset and angry,
and even bed wetting.(43, 44)
Bed wetting could be the
most disturbing symptom to most of the families we have interviewed during our
study.
Further studies with a
broader area and perhaps longer follow up periods than this study to elicit the
true size of the problem of PTSD among children in the area of Gaza are needed.
Conclusion
The Gaza strip area suffered to a massive extent
over the past years which led to a serious frequency of post traumatic stress
disorder amongst its children. In view
of the persistent threats, siege, and lack of social and medical support,
chances are little of having a decline in the symptoms of post traumatic stress
disorder as well as a decrease in the number of new post traumatic stress
disorder cases.
References
1.Thabet AA, Abu Tawahina A, El Sarraj E, et al. Exposure to war trauma and PTSD among parents and children in the Gaza strip. European Child Adolescent Psychiatry 2008 Jun; 17(4):191-199
2.Nader
K, Pynoos R, Fairbanks
L, et al. A
preliminary study of PTSD and grief among the children of Kuwait
following the Gulf crisis. Br J Clin Psychol 1993; 32: 407–416.
3.Laor
N, Wolmer L, Mayes L, et al. Israeli
pre-school children under scuds: a 30-month follow-up. J Am Acad Child
Adolesc Psychiatry 1997; 36: 349–356.
4. Ahmad
A, Sofi MA, Sundelin-Wahlsten V,
et al. Posttraumatic
stress disorder in children after the military operation “Anfal”in Iraqi
Kurdistan. Eur Child Adolesc Psychiatry 2000; 9: 235–243.
5.Kuterovac
G, Dyregrov A, Stuvland R.
Children in war: a silent majority under stress. Br J Med Psychol 1994;
67: 363–375.
6. Ajdukovic
M. Displaced adolescents in Croatia:
sources of stress and post traumatic stress reaction. Adolescence 1998;
33: 209–217.
7.Papageorgiou
V, Frangou-Garunovic A, Iodanidou R, et al. War trauma and psychopathology in Bosnian
refugee children. Eur Child Adolesc Psychiatry 2000; 8: 84–90.
8.Smith
P, Perrin S, Yule W, et al. War
exposure and maternal reactions in the psychosocial adjustment of children from
Bosnia-Herzegovina. J Child Psychol Psychiatry 2001; 42: 395–404.
9.Barenbaum
J, Ruchin V, Schwab-Stone M. The
psychosocial aspects of children exposed to war: practice and policy
initiatives. J Child Psychol Psychiatry 2004; 45:41–62
10. Montogmery E, Foldspan A. Validity of PTSD in a sample of refugee children: can a separate
diagnostic entity be justified? Internation Journal of Methods in
Psychiatric Research 2006; 15(2):64-74.
11. Vernberg EM. Children responses to disaster: Family and system
approaches. In R. Gist & B. Lubin (Eds.), Response to disaster:
Psychological, community and ecological approaches (Washington, DC:
Taylor & Francis. 1999; 193–209.
12.Donnelly CL, Amaya-Jackson L. Post-traumatic stress disorder in children and adolescents: epidemiology, diagnosis and treatment options. Paediatr Drugs 2002; 4(3):159-170..
13.Monahon C. Children and trauma: parents
guide to helping children heal. Toronto:
Maxwell Macmillan. 1993.
14. American Psychiatric Association
Diagnostic and statistical manual of mental health disorders: text revision, 4th
edn. Author, Washington 2000.
15.Keppel-Benson JM, Ollendick TH. Post-traumatic stress disorder in children and
adolescents. In: Saylor JF (ed) Children and disasters. Plenum, NewYork 1993; 29–44
16.Cohen JA. Practice parameters for the assessment and treatment
of children adolescents with posttraumatic stress disorder. Am Acad Child
Adolesc Psychiatry 1998; 37:4S–26S
17.Sundlin-Wahlesten V, et al. Traumatic experiences and post-traumatic stress
reactions in children from Kurdistan and Sweden. Act Paediatr 2001; 90:563-
568.
18. Saigh PA. The development of posttraumatic stress disorder following
four different types of traumatization. Behav Res Therapy 1991; 29:213–216.
19. Thabet AA, Abed Y, Vostanis P. Emotional
problems in Palestinian children living in a war zone: a cross-sectional study. Lancet 2002; 359(9320):1801-1804.
20.Bal A, Jensen B. Post-traumatic stress disorder symptom clusters in
Turkish child and adolescent trauma survivors. European Child & Adolescent Psychiatry2007; 16(7): 449-457.
21. Dyregrov A, Gjestad R, Raundalen M. Children exposed to warfare: a longitudinal study. J
Traumat Stress (2002) 15: 59-68.
22.Mahmoud M, Mohammadi MR, Mohammad BA. Post-traumatic stress disorder symptoms of children
following the occurrence of tehran
city park disaster. The Journal of Psychology: Interdisciplinary and Applied
2006; 140(3): 181 – 186
23.Hadi FA, Llabre MM. The Gulf crisis experience of Kuwaiti children:
Psychological and cognitive factors. Journal of Traumatic Stress 1998;
11: 45-56.
24.Qouta S, Punamaki R, El Sarraj E. Prevalence and determinants of PTSD among Palestinian
children exposed to military violence. Eur Child Adol Psychiatry 2003; 12:265–272
25. Thabet AA, Abed Y, Vostanis P. Comorbidity of post-traumatic stress disorder and
depression among refugee children during war conflict. J Child Psychol
Psychiatry 2004; 45:533–542
26. Thabet AA, Abed Y, Vostanis P. Emotional problems in Palestinian children living in
a war zone: a crosssectional study. Lancet 2002; 359:1801–1804
27.Lonigan C, Shannon M. Taylor C, Finch
J, Sallee F. Children exposed
to disaswter: II, Risk factors for the development of post traumatic
syptomatology. J Am Acad Child Adol Psychiatry 1994; 33:94-105
28.Qouta S, Punamaki R, El Sarraj E. House
demolishion and mental health: Victims and witnesses. J Soc Distress Homless 1997; 6:203-211
29. Smith P, Perrin S, Yule W, Hacam B,
Stuvland R. War exposure
among, children from Bosnia-Herzegovina: psychological adjustment in a
community sample. J Traumat Stress 2002; 15: 147–156
30.Pfefferbaum B. Posttraumatic stress disorder in children: a review
of the past 10 years. J Am Acad Child Adoles Psychiatry 1997; 36:1503–1511
31.Chieko, et
al. Prevalence of post-traumatic stress disorder in incarcerated juvenile
delinquents in Japan Psychiatry and Clinical Neurosciences. 2004; 58(4): 383-388.
32.Steiner H, Garcia IG, Matthews Z. Posttraumatic stress disorder in incarcerated juvenile delinquents. J Am Acad Child Adolesc Psychiatry 1997;
36: 357–365.
33. Cauffman E, Feldman SS, Waterman J, et al. Posttraumatic stress disorder among female juvenile
offenders. J Am Acad Child Adolesc Psychiatry 1998; 37: 1209–1216.
34.Heptinstall E, Vaheshta S, Eric
T. PTSD and depression in
refugee children, associations with pre-migration trauma and post-migration
stress. Eur Child adolesc Psychiatry 2004; 13: 373-380
35.Habimana TME, Biron C. The qubec adolescent refugee project: Psycopathology
and family variables in a sample from 35 nations. J Acad Child Adolesc
Psychiatry 1999; 38: 1426-1432.
36. Weisenberg M, Schwarzwald J, Waysman
M, et al. Coping of
school-age children in the sealed room during scud missile bombardment and
postwar stress reactions. J Consult Clin Psychol 1993; 61:462–467
37. Nader KO, Pynoos RS. The children of Kuwait after the Gulf crisis. In: Leavitt
LA, Fox NA (eds) The psychological effects of war and violence on children. Lawrence Erlbaum, New Jersey, London.
1993; 181–195
38. Sack WH, Clarke GN, Seeley J. Posttraumatic stress disorder across two generations
of Cambodian refugees. J Am Acad Child and Adoles Psychiatry 1995; 34:1160–1166
39.Jensen PS, Shaw J. Children as
victims of war: current knowledge and future research needs. J Am Acad Child
& Adoles Psychiatry 1993; 32:697–708
40. Pfefferbaum B. Posttraumatic stress disorder in children: a review
of the past 10 years. J Am Acad Child Adoles Psychiatry 1997; 36:1503–1511
41.Punamaki RL, Puhakka T. Determinants and effectiveness of children’s coping
with traumatic experiences. Intern J Dev Behav 1997; 21:349-370.
42.Kuterovac-Jagodić G. Posttraumatic stress symptoms in Croatian children exposed to war: a prospective study. J Clin Psychol 2003 Jan; 59(1):9
43. Eidlitz M, Shuper A, Amir J. Secondary enuresis:
post-traumatic stress disorder in children after car accidents. Israel Medical
Army Journal 2000; 2:135–137
44. Albano AM, Miller PP, Zarate R, et al. Behavioral assessment and treatment of PTSD in
prepubertal children: Attention to developmental factors and innovative
strategies in the case study of a family. Cognitive and Behavioral Practice 1997; 4(2):
245-262
Appendix 1: