J. Child Psychol. Psychiat. Vol. 40, No. 3, pp. 385–391, 1999
Cambridge University Press
? 1999 Association for Child Psychology and Psychiatry
Printed in Great Britain. All rights reserved
Post-traumatic Stress Reactions in Children of War
Abdel Aziz Mousa Thabet
Gaza Community Mental Health Programme, Palestine
University of Leicester, U.K.
The aims of this study were to estimate the rate of post-traumatic stress reactions in
Palestinian children who experienced war traumas, and to investigate the relationship
between trauma-related factors and PTSD reactions. The sample consisted of 239 children
of 6 to 11 years of age. Measures included the Rutter A2 (parent) and B2 (teacher) scales, the
Gaza Traumatic Event Checklist, and the Child Post-Traumatic Stress Reaction Index. Of
the sample, 174 children (72?8%) reported PTSD reactions of at least mild intensity, while
98 (41%) reported moderate?severe PTSD reactions. Caseness on the Rutter A2 scale was
detected in 64 children (26?8%), which correlated well with detection ofPTSD reactions, but
not with teacher-detected caseness. The total number of experienced traumas was the best
predictor of presence and severity of PTSD. Intervention programmes for post-war children
need to be evaluated, taking into account developmental and cultural aspects, as well as
characteristics of the communities involved.
Keywords: Post-traumatic stress, war, trauma, children.
Abbreviations: CPTSD-RI: Child Post-Traumatic Stress Reaction Index; PTSD: post-
traumatic stress disorder.
In the last 15 years, there has been substantial research
in the phenomenology and prevalence of post-traumatic
different ethnic groups and cultures. The majority of
studies refer to young people exposed to natural cata-
post-flood and 7% at 17 years; Green et al., 1994), and
hurricane disasters (short-term prevalence of 3–9%;
Garrison et al., 1995; Shannon, Lonigan, Finch, &
Taylor, 1994); also, following earthquakes, with rates
varying from 37% to 91%, depending on the proximity
(Pynoos et al., 1993). Other researchers investigated
children who had been exposed to community violence.
Pynoos, Frederick, and Nader (1987) studied children
who had been exposed to a sniper attack at school.
Nearly 40% were found to have moderate to severe
Fairbanks, and Frederick (1990) assessed the same
children and reported that 74% of those most severely
exposed in the playground still reported high levels of
later, Nader, Pynoos,
Requests for reprints to: Panos Vostanis, Professor of Child
Psychiatry, University of Leicester, Greenwood Institute of
Child Health, Westcotes House, Westcotes Drive, Leicester
LE3 0GU, U.K.
PTSD, and 19% of unexposed children reported some
degree of PTSD. Epidemiological studies differ in their
methodology and instruments used (screening, interview-
ing, two-stage procedure) and their sample size.
The impact of war on children has also attracted the
attention of the research community. Kinzie, Sack,
Angell, Manson, and Rath (1986) followed up children
who had experienced war trauma, 4 years after they left
Cambodia, and found that 50% had developed PTSD
and mild but prolonged depression. In a 15-year follow-
up of 59 Cambodian young adults, Hubbard, Realmuto,
Northwood, and Masten (1995) established a prevalence
of 24% for PTSD, and a lifetime prevalence of 59% for
the same disorder. Nader, Pynoos, Fairbanks, Al-Ajeel,
and Al-Asfour (1993), in a study of Kuwaiti children
following the Gulf War, found that 70% reported
et al. (1995) established PTSD in 25% and depression in
17% of a small sample of Bosnian adolescents who had
moved to America during the Yugoslavian war, and
Ahmad (1992) found the same rate in displaced Kurdish
children. Although depressive symptoms were equally
elevated in Croatian children during the war, displaced
(refugee) children reported more sadness and fear than
local children, who had not moved from their home
residence (Zivcic, 1993).
In addition to the prevalence of PTSD, mental health
problems have been studied in war victims in relation to
experienced traumas. In Israel, about 40% of kibbutz
386A. A. M. THABET and P. VOSTANIS
children presented with bereavement reactions of clinical
significance, including behavioural problems and social
impairment, 3 years after their father’s death in war
of 7 years tended to have a narrower awareness and
differentiation of their broader social environment
(Lifshitz, 1976). In a study of 108 Palestinian children in
the Gaza Strip, Qouta, Punamaki, and El Sarraj (1995a)
found that the number of traumatic experiences was
relatedto high levels of neuroticism and to impairment of
attention, concentration, and memory.
Some studies indicate that there may also be culturally
determined variations in the presentation of anxiety or
trauma-related disorders. Abu Hein, Qouta, Thabet, and
El Sarraj (1993), for example, found a high rate (25%) of
conversion fits in Palestinian children living in the Gaza
Strip and exposed to traumatic events during the war.
Palestinian children living in the West Bank were also
found to suffer predominantly from behavioural and
psychosomatic problems (Baker, 1990). Behavioural
in villages or cities. Somatising symptoms, on the other
hand, were more severe within the refugee camps and
villages. In another study from the Middle East, during
the Lebanon civil war, Farhood et al. (1993) found
considerable prevalence of somatising symptoms, such as
headaches, in both male and female children.
The aims of this study were to investigate: (1) the
prevalence of post-traumatic
Palestinian children who experienced war, (2) the re-
lationship between traumatic experiences, behavioural
and emotional problems, and PTSD reactions, and (3)
the nature and frequency of PTSD reaction items in this
particular cultural sample.
The Gaza Strip is an elongated area that stretches along the
Mediterranean Sea, between Israel and Egypt, covering
Mid-zone, Khan Younis, and Rafah. In 1995, the Gaza Strip
population was 860,369, excluding returnees from abroad
following the peace process. The Gaza Strip has a high
population density of 2150 people per km?, which is an index of
environmental adversity. The refugee population is 62?6% of
the total. About 55?1% live in 8 crowded camps and the
remaining 44?9% live outside the camps in rural (villages) and
urban areas (towns). In 1995, 50?8% of the population were
under 15 years of age, another risk factor for child psy-
In the first stage (Thabet, 1998), 981 children of 6–11 years
were selected by stratified quasi-randomisation from the 97
elementary schools of the 5 districts, to be screened by
teachers for behavioural and emotional problems using the
Rutter B2 Scale (Rutter, 1967). The return rate of the
questionnaires was very high (97%). The number of children
screened according to the original sample was 959. The
‘‘caseness’’ rates (i.e. possible presence of any mental health
disorder) were calculated using previously established cut-off
scores of 9 (Rutter, Tizard, & Whitmore, 1970). There were 422
children (44%) who scored positive and 537 (56%) who scored
In the second stage, 25% of children were randomly selected
for collection of self-reported and parent-rated data, while
maintaining the ratio between positive:negative cases of
44%:56%. The sample of this study therefore consisted of 239
children (105 positive and 134 negative cases). There were 129
boys and 110 girls. The mean age of the sample was 8?9 years
(range: 6–11 years). According to place of residence, 42 came
30 from the Middle area (12?6%), 41 from the Khan Younis
attended state schools (N?227, or 95%), while 12 attended
private schools (5%).
Rutter Scale A2 for completion by parents (Rutter et al. 1970).
This widely used and standardised measure of behavioural and
emotional problemsin epidemiological research has been found
to correlate well with clinical interviews and to distinguish
clinical from nonclinical subjects, with a high degree of
sensitivity and specificity for children of 6–13 years. Different
cut-off scores have been established according to sex and ethnic
origin (Elander & Rutter, 1996). The scale consists of 31 items
measuring behavioural and emotional problems on a 0–2 scale.
Children with a total score of 13 or more have been found to be
potential ‘‘cases’’, i.e. presenting with a possible mental health
Rutter Scale B2 for completion by teachers (Rutter, 1967).
Thisistheequivalent26-item form forteachers.Childrenwith a
total score of 9 or more have been found to be potential cases.
The Rutter Scales A2 and B2 were translated into Arabic,
following meetings with teachers and piloting of the translated
Gaza Traumatic Event Checklist (Abu Hein et al., 1993).
The initial checklist was developed by the research department
of the Gaza Community Mental Health Programme and
consisted of 17 items covering different types of traumatic
events that a child may have been exposed to (tear gas, beating,
witnessing beating, breaking limbs, imprisonment, siblings’
imprisonment, injury, night raids, humiliation, and detention).
or ‘‘no’’ statements). Traumatic experiences can be classified as
‘‘few’’ (less than 5 traumatic events), ‘‘frequent’’ (5–9 events),
of the checklist was used in this study, with 21 items. These
included different sensory types of exposure to traumatic
Child Post-Traumatic Stress Reaction Index (CPTSD-RI:
Pynoos et al., 1987).The CPTSD-RI is a 20-item self-report
scale designed to assess post-traumatic stress reactions of
children of 6–16 years following exposure to a broad range of
traumatic events (Frederick, 1985). The scale has been found
valid in detecting PTSD according to DSM-III-R criteria
(American Psychiatric Association, 1987). Inter-rater reliability
for this instrument when administered by a clinician has been
reported to be high, with Cohen kappa of ?87 for inter-item
agreement (Pynoos et al., 1987). Items are rated on a 0–4 scale.
Scores were classified as ‘‘mild PTSD reaction’’ (total score of
12–24), ‘‘moderate’’ (25–39), ‘‘severe’’ (40–59), and ‘‘very
severe’’ (above 60–Goenjian et al., 1995). The CPTSD-RI was
also translated into Arabic, following piloting.
Descriptive statistics were used to present the characteristics
of the sample. Within-sample associations between continuous
variables were tested by Spearman rank correlation test. The
proportion of cases identified by different measures and
related samples. The associations of categorical (e.g. types of
387PTSD IN WAR CHILDREN
traumas) and continuous variables with presence of PTSD
reactions or caseness on the Rutter scales were tested by series
of stepwise forward regression analyses.
The Rutter Scales
According to parent-completed Rutter A2 Scales
(100% completion rate), 64 children (26?8%) exceeded
Traumatic Experiences: Gaza Traumatic Event Checklist
Witnessing beating of close relative
Witnessing beating of friend
Witnessing killing of close relative
Witnessing killing of friend
Hearing of killing of close relative
Hearing of killing of friend
Witnessing shooting of close relative by
rubber?plastic or real bullets
Witnessing shooting of friend
Shot by rubber?plastic or real bullets
Witnessing relative’s detention
Witnessing friend’s detention
Tear gas inhalation
Witnessing night raids
Witnessing day raids
Having limbs broken
Witnessing breaking relative’s limbs
Witnessing breaking friend’s limbs
Witnessing house closure?demolition
Witnessing friend’s house
Positive and Negative Subjects on the Teacher Rutter A2 Scales
Positive (N?105) Negative (N?134) Difference
Mean age (range)9?1 (6–11)8?9 (6–11)
χ?(1)?0?03, p??86SexMale: 56 (53?3%)
Female: 49 (46?7%)
North area: 22 (20?9%)
Gaza: 37 (35?2%)
Middle area: 13 (12?4%)
Khan Younis: 23 (21?9%)
Rafah: 10 (9?6%)
Male: 73 (54?5%)
Female: 61 (45?5%)
North area: 20 (14?9%)
Gaza: 66 (49?3%)
Middle area: 17 (12?7%)
Khan Younis: 18 (13?4%)
Rafah: 13 (9?7%)
Area of residence
Mean number of experienced
Caseness on parent Rutter B2 Positive: 38 (36?2%)
Positive: 26 (19?4%)McNemar test: χ??17?2,
McNemar test: χ??11?9,
McNemar test: χ??8?7,
Mann-Whitney test: z?2?47,
Any PTSD reaction84 (80%) 90 (67?2%)
52 (49?5%)46 (34?3%)
Mean CPTSD-RI score
22?2 (0–45) 18?1 (0–46)
the cut-off score of 13. The mean total score was 8?27
(SD 7?0), with item frequency ranging from 0 to 32. The
items most frequently rated as ‘‘certainly applies’’ (scale
2) were: being restless (N?48, or 20?1%), irritable (N?
33, or 13?8%), worrying (N?26, or 10?9%), and bed
wetting more than once per week (N?25, or 10?5%).
Somatising items were not rated very highly: 13 children
(5?4%) were rated as having headaches and 6 children
(2?5%) as having asthma (both on scale 2).
The mean total score on the Rutter teacher scale was
10?5 (range 0–43). Teachers reported worrying (N?52,
or 21?8%), restlessness (N?52, or 21?8%), fearfulness
(N?37, or 15?5%), and poor concentration (N?36, or
15?1%) as the most frequent items on scale 2. Ten
caseness for any mental health disorder by parents and
teachers differed significantly (McNemar test: χ??17?2,
p??0005). There was no significant sex difference on the
rates of caseness according to either parent or teacher
scales. Demographic data and instrument scores are
presented in Table 2 for both positive and negative
subjects on the teacher Rutter A2 scales, according to
which this sample was selected.
Traumatic Experiences (Gaza Traumatic Events
Children were exposed to a wide range of traumatic
experiences. Of the 21 possible exposures, the average
0–15). The frequency of reported items is presented in
Table 1. Significantly more boys than girls had witnessed
the breaking of limbs of a close friend (χ??5?6, p??02)
and demolition of their house (χ??6?1, p??01). The
number of traumas experienced was significantly corre-
lated with children’s age (Spearman rank correlation
coefficient R??28, p??0005), i.e. older children had
experienced more traumatic events.
388 A. A. M. THABET and P. VOSTANIS
Self-reported CPTSD-RI Items ((N?239)
of the time
Regular fear (A2)
Fear of recurrence
44?2 42?0 13?8
52?7 37?3 10?0
33?9 23?4 42?7
A–D: items included in DSM-IV criteria (309?81 Post-
traumatic stress disorder; American Psychiatric Association,
Post-traumatic Stress Disorder Reactions
Overall, 174 children (72?8%) reported post-traumatic
stress reactions of at least mild severity: 76 (31?8%)
reported mild reactions, 85 (35?6%) moderate, and 13
(5?4%) severe PTSD reactions. The mean CPTSD-RI
score was 19?9 (SD?12?9, range 0–46). The most
frequently reported symptoms were: thoughts and fear
related to the trauma, anhedonia, impaired concen-
tration, and avoidance of situations that reminded them
of the trauma (Table 3). There was no significant sex
difference on the rates of PTSD reactions or total PTSD
scores. There was significant difference on the ratings of
only one PTSD symptom (event identified as traumatic),
which was rated higher by boys (Mann-Whitney U test
PTSD reactions were also dichotomised as (a) present?
absent, and (b) absent or mild?moderate or severe, which
was entered as the dependent variable in a series of
stepwise logistic regression analyses. The total number of
traumatic events experienced (B?0?74, p??0005) and
living north of Gaza City (which reflects a refugee
population: B?1?79, p??006) best predicted presence
of PTSD reaction. The total number of traumatic events
also best predicted moderate?severe PTSD reactions
The total number of experienced traumas and the total
coefficient of correlation R??64, p??000). Among the
traumatic events, presence of PTSD reaction was best
predicted by having experienced tear gas attacks (B?
0?95, p??001), and having witnessed the beating of a
friend (B?0?95, p??001) or day raids (B?0?60, p?
?006). A moderate to severe PTSD reaction was best
predicted by having experienced tear gas attacks (B?
0?71, p??001), and having witnessed the killing (B?
0?68, p??003) or beating of a friend (B?0?41, p??01).
The proportion of detected ‘‘cases’’ by parents on the
Rutter A2 scale and detected PTSD reactions on the
CPTSD-RI did not differ significantly (McNemar test:
χ??0?00, p??99). There was, however, significant dif-
ference on the detection of ‘‘caseness’’ by teachers on the
Rutter B2 scale and of PTSD on the CPTSD-RI (χ??
This study found high rates of post-traumatic stress
reactions in children of primary school age who had
experienced war. According to children’s reports, 73?2%
reported PTSD reactions of at least mild severity, whilst
39% reported moderate to severe reactions. A limitation
was the absence of assessment of global functioning or a
clinical interview in addition to the CPTSD-RI, in order
to establish whether children met all criteria for PTSD.
Although a number of studies have used the CPTSD-RI
and the classification of its total scores into mild,
moderate, severe, and very severe reactions (e.g. Nader et
al., 1993; Shaw et al., 1995), the clinical implications of
the scoring system remain unclear. Goenjian et al. (1995)
found that the ‘‘severe’’ categories correctly identified
78% of subjects who met DSM-III-R criteria for PTSD.
However, if the CPTSD-RI was used for screening
purposes,children of at least‘‘moderate’’severity should
also be included. About 27?5% of children were potential
cases of mental health disorder according to parental
ratings on the Rutter A2 scale, a rate similar to other
deprived urban populations.
Children who lived north of Gaza City, an area of
refugeepopulationmay reflect mediating adversities such
as relocation and disruption of school life or peer
relationships. It could also reflect higher exposure to life
events such as house demolition (Qouta, Punamaki, & El
Sarraj, 1997). The previous finding of dose-effect re-
lationship between cumulative trauma and PTSD symp-
replicated in this population. The research was carried
out following the peace accord. In a longitudinal study of
Palestinian children living in the Gaza Strip, Qouta,
389PTSD IN WAR CHILDREN
Punamaki, and El Sarraj (1995b) found that their level of
neuroticism was significantly lower after the peace treaty
than before. Earlier exposure to traumatic experiences
and nonacceptance of the treaty (continuing political
activity and nonparticipation in peace treaty festivities)
predicted increased neuroticism and low self-esteem.
Although we investigated the extent of trauma and its
impact on PTSD, other possible mediating variables,
such as family functioning, adult perceptions of trauma,
or perceived parenting (Elizur & Kaffman, 1983; Laor et
al., 1997; Punamaki, Qouta, & El Sarraj, 1997), and their
interaction with trauma, were not accounted for in this
study. Secondary adversities such as school and social
network disruption are also important. For example,
Farhood et al. (1993) found that Lebanese family
members were confident that they could rely on social
support to deal with problems of various natures during
the war. A high level of social support, family cohe-
siveness, and family communication has been found to
protect children by mediating the effect of war trauma
Despite the war, there was relative stability in our
population to enable them to continue to attend school,
which could thus form the basis for detection of children
most at risk and intervention (Yule, 1992, 1994). General
screening instruments with high sensitivity and specificity
such as the Strengths and Difficulties Questionnaire,
which has since extended the Rutter scales used in this
study (Goodman, 1997), would be appropriate. As
mentioned earlier, the use of specific instruments such as
the CPTSD-RI for screening purposes is less well es-
tablished, in which case a cut-off score indicative of ‘‘low
to moderate’’ severity could be adopted.
As there was a substantial proportion of cases unde-
tectedby teachers, screening methods should also involve
children and parents. The significant difference on rates
of cases detected by parents and teachers could be related
to the nature and presentation of mental health problems
(situation-specific) or lack of awareness by teachers
(Kent, Vostanis, & Feehan, 1995). Discrepancy between
teacher and parent reports has been found previously on
different child mental health symptoms and disorders,
particularly emotional problems such as those character-
ising this sample (Kolko & Kazdin, 1993). Compliance
with such programmes is likely to be high in close
communities, as demonstrated by the participation rate
in this study. Goenjian et al. (1995) suggested a realistic
and cost-effective method of screening, i.e. periodic
monitoring of secondary adversities that may have a
cumulative risk effect and precipitate new-onset dis-
A ‘‘cultural’’ hypothesis on the phenomenology of
mental health and PTSD symptoms was not supported.
For example, children did not present predominantly
with somatising or behavioural problems. High rates of
cognitive and emotional PTSD symptoms were reported.
Previous research with victims of war trauma has sup-
ported the validity of PTSD ‘‘beyond the barriers of
culture and language’’ (Sack, Seeley, & Clarke, 1997). In
another epidemiological study by the authors with
a different and older sample of Palestinian children
(9–13 years of age; Thabet & Vostanis, 1998), children
reported high rates of significant anxiety problems
(21?5%) and similar phenomenology to Western popu-
lations. Anxiety symptoms were associated with socio-
economic deprivation, while the higher prevalence rates
among females was explained by the 12–13-year-old
children of that sample (in contrast with the younger
sample of the present study).
Future research could address cultural variations by
studying the perceived impact of the trauma and the
children’s ‘‘meaning’’ of it among different cultures.
Eisenbruch (1991) proposed an interesting concept of
‘‘cultural bereavement’’, which includes the refugees’
picture—what the trauma meant to them; their cultural
ways of signalling distress; and their cultural strategies
for overcoming it. At the same time, certain coping
mechanisms and protective factors appear to be in-
dependentof culture and societal structure.Ina review of
the psychological effects of war on children, Jensen and
Shaw (1993) put forward a positive message on the
development of coping skills due to children’s ‘‘cognitive
immaturity, plasticity and innate adaptive capacities,
which can protect from trauma in low-to-moderate war
The development and evaluation of treatment inter-
ventions for post-war child populations, where ‘‘natural
community groupings exist’’ (Yule, 1994), can be school-
and group-based. Galante and Foa (1986) demonstrated
the effectiveness of school-based group treatment for at-
risk children following earthquake in Italy (seven hourly
sessions for one week). Brief cognitive-behavioural treat-
ment that aimed at improving children’s locus of control
and self-esteem has also been described (Baker, 1990).
Parents should be involved in these programmes as far as
Acknowledgements—The authors are grateful to all families
and teachers who participated. Also to the Palestinian Min-
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