Post-traumatic stress disorder among school age Palestinian children☆
Introduction
Palestinians are at high risk of exposure to traumatic events that have the capacity to produce traumatic stress reactions. Consequently, mental health practitioners and scholars have become increasingly interested in the psychological study of trauma, mainly post-traumatic stress disorder (PTSD) (Afana, Dalgard, Bjertness, Grunfeld, & Hauff, 2002; El Sarraj, Punamaki, Salmi, & Summerfield, 1996; Khamis, 1993, Khamis, 2000a; Thabet et al., 2002, Thabet et al., 2004; Thabet & Vostanis, 2000). More specifically, Khamis (1993) has investigated PTSD among Palestinian males who sustained serious bodily injuries during the intifada, the Palestinian popular uprising in the Israeli-occupied West Bank and Gaza Strip that started in December 1987. The results indicated that the level of PTSD found was markedly high. However, there were no significant differences for demographic, situational, and trauma-related variables except for age: PTSD among adolescents was significantly higher than among adults. It was speculated that the injury itself was so intensely overwhelming that the other variables were overshadowed. On the other hand, researchers have investigated patients attending primary health care centers in the Gaza Strip (Afana et al., 2002). The prevalence of PTSD was found to be 29% whereas it was 36% in patients who were exposed to traumatic events. Also, the results indicated that PTSD was more likely associated with the female gender as well as with those who had lesser educational attainment. Differences in PTSD symptoms among male Palestinian political ex-prisoners from the Gaza Strip have been found with respect to the degree of exposure to torture, and to family and economic difficulties (El Sarraj et al., 1996). Previous studies have also investigated PTSD in Palestinian families who experienced intifada-related trauma. Among the various variables studied, PTSD was more associated with women, Gazans, families who had a member killed, and with trauma-induced stress (Khamis, 2000a). To date, there have been few studies that investigated PTSD in Palestinian children (Thabet et al., 2002, Thabet et al., 2004; Thabet & Vostanis, 2000). Viewed collectively, these studies have not been successful in addressing demographic and other differences between groups that constitute potential confounding variables and can distort research findings. For example, in a study that investigated PTSD reactions in children who had experienced war trauma (Thabet & Vostanis, 2000), the results indicated a decrease in rates and severity of PTSD in children a year after the initial assessment; however, PTSD reactions in relation to demographics and mediating variables were not examined. Also, the nature and severity of emotional problems including symptoms of post-traumatic stress (PTS) in Palestinian children have been investigated (Thabet et al., 2002). The results indicated that symptoms of PTS were more often reported by children who were exposed to bombardment in comparison to children in the control group. Yet, concerns regarding the quantity of missing demographic information, research design, and sample selection weakened the conclusions that could be drawn from these studies. One recent study (Thabet et al., 2004) examined the prevalence and nature of comorbid post-traumatic stress reactions and depressive symptoms, and the impact of exposure to traumatic events on both types of psychopathology among refugee children living in the Gaza Strip. Although the results indicated that children were at high risk of suffering from PTSD and depressive disorders, exposure to trauma was not found to have a unique association with PTSD. The authors concluded by stressing the importance of distinguishing between exposure to trauma, child-related, and environmental factors in the interpretation of underlying mechanisms that produce PTSD and other types of psychopathology in children.
Drawing from the aforementioned studies, PTSD has been more extensively studied in adults than in children and in populations at risk than in the general population, particularly school-age children. Thus far, there has been little formal consideration of the variability in PTSD seen in Palestinian children.
In general, few studies have investigated school age children in non-traumatic situations (Berna & Hyman, 1993; Motta, 1994), and as a result the prevalence of PTSD in these children is unknown. Estimates of the prevalence rates of PTSD have varied from 2% in school—age children (Berna & Hyman, 1993) to 50% in children who have experienced war atrocities (Anthony, 1986). The discrepancy in these results may be attributed to the magnitude and severity of the stressors (Khamis, 1993, March, 1993, Pynoos, 1990).
Many stressors have been identified as producing childhood PTSD, including child abuse (i.e., physical and sexual) in the family of origin (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993; McCormack, Burgess, & Hartman, 1988). Less common is the study of other forms of ongoing familial maltreatment such as psychological maltreatment, gender inequities, harsh discipline, and family ambiance.
The present study examined how child characteristics, socioeconomic status, family environment and parental style of influence are related to PTSD among Palestinian school age children.
A major departure from previous investigations should be noted. Despite the burgeoning amount of research on the association of exposure to child maltreatment and the risk that PTSD-like symptoms will occur in children (Hart, Germain, & Brassard, 1987), the cumulative impact of child's experiences in home environment has not been addressed adequately. Emphasis in the diagnosis of post-traumatic stress disorder on the experience of particular stressor events as the necessary but not sufficient etiological factor (APA, 1994) highlights the importance of accurately assessing the family environment of children. Therefore, the purpose of this study was to investigate the prevalence of PTSD in school age Palestinian children as well as the types of traumatic events that these children encountered. It examined the variables that distinguished children with PTSD and children with non-PTSD, such as child characteristics, socioeconomic status, family environment and parental style of influence. Specifically, it was predicted that PTSD rates in children would differ as a function of child's age, gender, residential patterns (i.e., city, village, camp), and whether the child was working. Also, it was predicted that PTSD symptomatology in children would vary with the economic hardship that families encountered and the extent to which these families met their children's material needs. Finally, it was hypothesized that children who exhibited PTSD symptoms would be more likely to report higher levels of anxiety in home environment, psychological maltreatment, gender inequities, harsh disciplining, and lower levels of parental support.
Section snippets
Participants
The sample was 1,000 school age children, of whom 52.3% were males and 47.7% females. They ranged in age from 12 to 16 years (M = 14.18, SD = 1.60). The majority (86.4%) were Muslims; 13.6% were Christians. About 60.9% were from governmental schools; 18.8% from private schools; and 20.3% from United Nations Relief Work Agency (UNRWA) schools. Geographically, 84.6% were from the West Bank and 15.4% from East Jerusalem, representing various residential patterns, 11.2% from refugee camps, 56.9% from
Child characteristics and family data sheet
This brief questionnaire secured demographic information about the child. The child variables considered for this study were age, gender, residential patterns (urban, rural, and refugee camps), presence of disability and child's work if any. Children were asked if they had been physically abused in their families. Physical abuse was defined as being hit, punched, cut, pushed down by a parent or an adult (e.g., uncle, aunt, etc.) in such a way that resulted in injury ranging from bruises to
Prevalence of traumatic events
Approximately 54.7% of Palestinian school-age children (n = 547) reported experiencing at least one high-magnitude traumatic event in their lifetime. Political traumas inflicted by the Israeli army were the most common experienced events (270, 49.4%). Among these, 125 (22.9%) were injured, 96 (17.6%) involved a family member being killed, 45 (8.2%) imprisoned with beating, 4 (.7%) had their house demolished. Approximately 169 (30.9%) of the traumatized children reported being in a car accident,
Discussion
The most significant finding in this study was that a high proportion of Palestinian school-age children reported that they had experienced PTSD symptomatology. This high prevalence is comparable to the rate of PTSD found in children exposed to the stress of extreme political violence (Anthony, 1986, Goleman, 1986, Saigh, 1989). It is likely that the high rates of PTSD symptomatology in Palestinian children may be attributed to living under conditions of constant political oppression,
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This research has been funded by an internal grant from Bethlehem University, Bethlehem, West Bank, Palestinian Authority.