Predictors of psychological distress and positive resources among Palestinian adolescents: Trauma, child, and mothering characteristics
Introduction
War is not healthy for human beings, and children are especially vulnerable. Despite the international pledge to protect children from war violence, a great number still live in life-endangering conditions. Characteristic to modern wars is that children are forced to witness atrocities or even to take part in military activity. According to UN statistics, an estimated 2 million children have been killed in armed conflicts in the past decade. Three times as many have been seriously injured or permanently disabled, many of them in armed confrontations and landmine accidents (Bellamy, 2003, Machel, 2003). The negative consequences of military trauma on child development and mental health are of great concern (Carlson, 2001; UN & UNICEF, 1998). In this study, we examine how military trauma in middle childhood predicts psychological distress and positive resources in adolescence. The participants are Palestinians, who spent their childhood in conditions of foreign military occupation, characterized by fighting, detentions, and destruction (Abu Hein, Qouta, Thabet, & El-Sarraj, 1993; B’Tselem, 1994, B’Tselem, 1998). The Palestinian Authority rule, following the Oslo Agreement in 1993, provided 7 relatively nonviolent years. The historical lull provided us the opportunity to study influences of childhood trauma and personal characteristics on peacetime adjustment in adolescence.
Research shows increased mental health problems among children living in conditions of war and military violence. These include PTSD that is intrusion, avoidance, and hyperarousal symptoms (Laor et al., 1997; Rosner, Powell, & Butollo, 2003; Smith, Perrin, Yule, Hacam, & Stuvland, 2002), depression (Saigh, 1991), anxiety and sleeping difficulties (Montgomery, 1998, Punamäki, 1998), and extended grief (Smith et al., 2002). War and military violence may also seriously interfere with children's and adolescents’ healthy identity formation (Punamäki, 1999, Punamäki, 2002), moral development (Baker & Shalhoub-Kevorkian, 1999), and social relationships (Elbedour, Van Slyck, & Stern, 1998).
Despite the great burden of war trauma, not all children are similarly vulnerable. There is evidence of “war children” showing impressive signs of endurance and resilience. Resilient children are those who, despite severe adversities and trauma, do not suffer from psychological and social problems or are able even to blossom (Apfel & Simon, 2000; Rutter, 2000). Research among Palestinian children shows that resiliency could be attributed to strong ideological and social commitment (Punamäki, 1996), high self-esteem, successful and active coping (Baker, 1990), and creative problem solving (Punamäki, Qouta, & El Sarraj, 2001). It has been noted that living in chronic life-endangering conditions forces children to balance between distress and resilience and to solve conflicts between fear and courage (Punamäki & Suleiman, 1989). In this study, the conceptualization of mental health involves both psychological distress, indicated by PTSD and depressive symptoms, and positive resources, indicated by resilient attitudes and satisfaction with quality of life.
Researchers have identified several issues that explain the differences in mental health and adjustment of children living in war conditions: the trauma itself, responses to it, characteristics of the child, relationships within the family, and community values and support. First, mental health consequences vary according to the severity, nature and meaning of trauma. There is evidence that multiple and cumulative traumatic stress and chronic trauma exposure increase the risk of childhood PTSD (Garbarino & Kostelny, 1996). Because family signifies a protective shield for children, witnessing humiliation, and violence toward family members is especially harmful for children's well-being (Macksoud & Aber, 1996; Punamäki, 1998). Traumatic scenes involving strong sensory impressions, for example, smell of dead bodies and voice of suffering people, constitute a serious risk for intrusive PTSD symptoms (Dyregrov, Gjestad, & Raundalen, 2002). Also one's own physical injury (Khamis, 1993; Miller, El-Masri, & Qouta, 2000) and threat to life (Smith, Perrin, Yule, & Rabe-Hesketh, 2001) are associated with high levels of PTSD, depression and anxiety among children in war zones.
Girls are found to be more vulnerable to psychological distress when facing war-related trauma than boys (Macksoud & Aber, 1996; Durakovic-Belko, Kulenovic, & Dapic, 2003; Dyregrov, Gupta, Gjestad, & Mukanoheli, 2000). However, Garbarino and Kostelny (1996) reported that Palestinian boys suffered more than girls from psychological problems when exposed to chronic military stress. Other findings among Palestinian children suggested that girls are more vulnerable to depression and anxiety, whereas boys show aggressive and other externalizing symptoms, especially when exposed to severe military trauma (Qouta, Punamäki, & El Sarraj, 2005) which is consistent with findings in general child populations (Kaslow, Gray-Deering, & Racusin, 1994). Girls’ greater vulnerability to depression in adolescence is explained by biological, psychological, and social factors. There is an increase of female hormones and changes in the mood-regulating brain functions in adolescence (Pickles et al., 2001). Further, girls are more often exposed to high stress and abuse, and their social status is conflicting (Petersen, Sarigiani, & Kennedy, 1991).
Both younger (Weisenberg, Schwarzwald, Waysman, Solomon, & Klingman, 1993) and older (Elbedour et al., 1998) children have been found to show psychological distress in exposure to war trauma. The vulnerability of younger children has been attributed to their less mature cognitive capacity and biased explanations of the reasons for traumatic events (Finkelhor, 1995). Adolescents in turn are at greater risk because they have a broader understanding of the dangerous consequences of war trauma (Berman, 2001). The child's age may not, however, be a risk factor in and of itself; rather, in each developmental stage children have both age-specific protective assets and vulnerabilities, and those shape their cognitive-emotional responses (Punamäki, 2002).
Although child characteristics such as beneficial personality, high intelligence and high self-efficacy are often mentioned as possible explanations for resiliency (Apfel & Simon, 2000), empirical research is scarce. A study among Palestinian children found that flexible cognitive style and high cognitive capacity were associated with good psychological adjustment and could even protect children from negative impacts of military violence (Qouta et al., 1995, Qouta et al., 2001). A balance between intelligence and creativity predicted good adjustment after military trauma (Punamäki et al., 2001). High self-efficacy has been found to protect children and adolescents from negative impacts of trauma in both peaceful (Cheever & Hardin, 1999) and war-ridden (Saigh, Mroueh, Zimmerman, & Fairbank, 1995) societies. Saigh et al. (1995) demonstrated that Lebanese children with low emotional regulation, poor problem solving skills, and feelings of helplessness were at high risk of PTSD.
Family factors play a crucial role in children's well-being in war and military violence. Findings show that good maternal mental health (Laor, Wolmer, & Cohen, 2001; Qouta et al., 2005, Smith et al., 2001) and adequate responses to trauma, such as image control (Laor et al., 2001) are associated with good psychological adjustment of the child. Barber, 1999, Barber, 2001 showed that a nurturing parenting style protected children's development and emotional well-being from the negative impact of military violence in Palestine and Balkan. Children who perceived their parents as harsh and punitive were more likely to develop antisocial behavior, whereas parental acceptance provided a buffer between military violence and adolescents’ depression (Barber, 1999). Garbarino and Kostelny (1996) provided evidence that Palestinian children from dysfunctional families were more vulnerable to the negative consequences of chronic military violence, when compared to children whose parents used positive styles. An additional study on Palestinians revealed that children who had loving and nonrejecting parents were more creative and efficient in problem solving than those from problematic families. The creativity and efficiency in turn could protect children's mental health despite exposure to military violence (Punamäki et al., 2001). Exposure to war trauma and violence, however, places great burdens for parents and may compromise their parenting quality. Qouta et al. (1995) showed, for instance, that children in families exposed to severe military trauma perceived both of their parents as strict, rejecting, and hostile, and their mothers as generally negative.
Coping theory is useful in conceptualizing children's responses to war trauma. According to Lazarus’ (1991) transactional theory, no stressful event of any magnitude can independently cause a deterioration of mental health. Trauma exposure should thus be conceptualized as a process in which the victim first appraises the meaning and severity of trauma, and then employs coping strategies to deal with it. Middle Eastern research suggests that children use both active and passive coping strategies in their attempts to process overwhelming experiences and regulate inner feelings (Punamäki & Puhakka, 1997; Weisenberg et al., 1993). There is some consensus in general coping research that active and problem-solving responses protect children's mental health, and passive withdrawal harms it (Compas, Malcarne, & Fondacoro, 1988; Finnegan, Hodges, & Perry, 1996). In the same vein, Baker (1990) found that, in conditions of military violence, Palestinian boys who participated in the national struggle were better adjusted than passive boys. A follow-up study among Palestinian children, however, showed that the positive impact of political activity was possible only once the military violence and life-threat were over (Punamäki et al., 2001). There is also evidence that active problem-solving coping is not always effective in war situations. Weisenberg et al. (1993) found that distractive and passive coping strategies were effective among Israeli children during the missile attacks. The perception of the controllability of the traumatic stress may be critical here. Coping researchers specify that problem-focused coping is mainly effective when the victims perceive the situation as being under control, but ineffective when they perceive it as out of control (Compas, 1998), as is objectively true in war and life-threat.
The research on child mental health in war and military violence is mainly cross-sectional and narrowly focuses on traumatic events and demographic factors as the only determinants of psychological adjustment. Exceptions are prospective studies on Israeli (Laor et al., 2001), Iraqi (Dyregrov et al., 2002), and Croatian (Kuterovac-Jagodic, 2003) children suggesting that although PTSD symptoms generally decrease with time, negative trauma, family and child characteristics make some children highly vulnerable. Our contribution to the literature is a long-term follow-up study that covers middle childhood and adolescence and provides a wide and developmentally adequate set of determinants of both psychological distress and positive resources. This is important because traumatic experiences interact with personal and family issues and confound with developmental tasks and conflicts.
The present study aims at understanding how traumatic stress, responses to violence, and child and family characteristics impact mental health in adolescence. Specially, we analyze how the nature of traumatic stress (military trauma, stressful life-events), child characteristics (gender, cognitive capacity, and neuroticism), child's responses to trauma (active coping), and mothering quality predict adolescents’ mental health. The mental health is conceptualized as psychological distress (indicated by PTSD and depressive symptoms) and positive resources (indicated by resilient attitudes and satisfaction with quality of life).
Section snippets
Participants and procedure
The participants are 65 Palestinian adolescents (17.6 ± .85 years; 52% girls) living in Gaza. The initial sample was 108 Palestinian children who were first studied during the Intifada I, when they were 10–11 years old (T1, 1993). These children were studied a second time during the period of the Palestinian Authority rule (T2, 1996; N = 86), and third time just before the beginning of the Al Aqsa Intifada (T3, 2000; N = 65). The initial sample was recruited from a community-based random sample of
Correlation analyses
Table 3 shows the Spearman bivariate correlations between predictors and dependent variables. The results show that the dependent variables of psychological distress and positive resources significantly correlated. For instance, PTSD symptoms were positively correlated with depressive symptoms (r = .66, p < .001), and negatively with satisfaction with life (r = −.46, p < .001). Significant correlations were found also between predictor variables: military trauma positively correlated with neuroticism (r
Discussion
Our aim was to understand how variables related to the trauma, child, and family would predict adolescents’ mental health, indicated by psychological distress and positive resources. The participants were Palestinian adolescents who had spent their childhood in conditions of military violence and national resistance. Our results in a longitudinal study showed that childhood traumatic stress increased psychological distress and decreased positive resources in adolescence even in relative calm
References (85)
- et al.
Effects of political and military traumas on children: The Palestinian case
Clinical Psychology Review
(1999) - et al.
Psychological theories of posttraumatic stress disorder
Clinical Psychology Review
(2003) Child rights and mental health
Cultural Societal Influences in Child and Adolescent Psychiatry
(2001)- et al.
Behavioral/cognitive conceptualization of posttaumatic stress disorder
Behavioral Therapy
(1989) - et al.
Depressed children and their families
Clinical Psychology Review
(1994) - et al.
Israeli preschools under Scuds: A 30-month follow-up
Journal of American Academy of Child and Adolescence Psychiatry
(1997) The development of posttraumatic stress disorder following four different types of traumatization
Behavior Research and Therapy
(1991)- et al.
Self-efficacy expectations among traumatized adolescents
Behavioral Research Therapy
(1995) - et al.
Overview of the SF-36 health survey and the international quality of life assessment (IQOLA) project
Journal of Clinical Epidemiology
(1998) - et al.
Traumatic and mental health of children in Gaza
British Medical Journal
(1993)