Psychological reactions to Israeli occupation: Findings from the national study of school-based screening in Palestine

Abstract

Children exposed to violent war-like and repeated political violence often experience a continued threat to life and their sense of safety, as well as a disruption of daily functioning. The purpose of the study was to examine the psychological impact of exposure to Israeli occupation on Palestinian school children in the West Bank and Gaza, Palestine. We assessed the association between exposure to occupation and the severity of posttraumatic symptoms and the inter-relationship between posttraumatic symptoms, functional impairment, somatic complaints, and coping strategies in school children. 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. Results showed that extensive exposure to violence was associated with higher levels of posttraumatic distress and more somatic complaints in both the West Bank and Gaza regions. More Gaza than West bank students reported symptoms meeting the criteria for PTSD, and more girls than boys in both groups reported somatic complaints. Thus, school-based screening can be an effective method for case identification of students showing PTSD symptoms as a result of exposure to political violence.

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Development
International Journal of Behavioral
DOI: 10.1177/0165025408092220
2008; 32; 290 International Journal of Behavioral Development
Ziad Abdeen, Radwan Qasrawi, Shibli Nabil and Mohammad Shaheen
screening in Palestine
Psychological reactions to Israeli occupation: Findings from the national study of school-based
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International Journal of Behavioral Development
2008, 32 (4), 290–297
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© 2008 The International Society for the
Study of Behavioural Development
DOI: 10.1177/0165025408092220
Children have been the tragic victims of armed conflict
throughout history. Today, wars take place in virtually every
part of the globe, either between or, more often, within nation
States – with one group fighting another in the same country.
These wars or armed conflicts also involve high levels of
violence (UNICEF, 2005). In public health terms, the cost of
violent war-like conditions on children’s lives is extensive,
multi-faceted, and pervasive.
For children, wars represent not only the risk of personal
physical endangerment, but also the loss of the security,
predictability, and structure of day-to-day life. Much of the
available research focuses on exposures to traumatic events
associated with violent war-like conditions and their subse-
quent psychiatric sequelae such as children’s acute responses
to air raids, bombardment, and family losses during the
Second World War (Brander, 1941; Dunsdon, 1941; Freud &
Burlingham, 1943), and on maternal and child mental health
during the Middle Eastern wars (Baker, 1990a; Bryce, Walker,
Ghorayeb, & Kanj, 1989; Macksoud, Aber, & Cohn, 1996;
Milgram & Milgram, 1976; Punamäki, 1987; Saigh, Green, &
Korol, 1996; Ziv & Israeli, 1973).
Research has been especially intensive on Kuwaiti children
during the nine-month Iraqi occupation (Abdel-Khalek, 1997;
Hadi & Llabre, 1998; Llabre & Hadi, 1994; Macksoud et al.,
1996; Nader & Pynoos, 1993; Nader, Pynoos, Fairbanks, Al-
Ajeel, & Al-Asfour, 1993) and on Israeli children during the
Iraqi Scud missile bombardment (Laor, Wolmer, & Cohen,
2001; Laor et al., 1997; Lavee & Ben-David, 1993; Rahav &
Ronen, 1994; Rosenthal & Levy-Shiff, 1993). The impact of
war atrocities on children’s mental health has been also care-
fully studied in the former Yugoslavia (Kuterovac-Jagodic´,
2003; Rosner, Powell, & Butollo, 2003; Smith, Perrin, Yule,
Hacam, & Stuvland, 2002; Smith, Perrin, Yule, & Rabe-
Hesketh, 2001) and Israel (Lavi & Solomon, 2005; Pat-
Horenczyk, 2005; Pat-Horenczyk & Abramovitz et al., 2007;
Pat-Horenczyk & Peled et al., 2007).
Despite the potentially profound impact of war-related
violence on young lives, the psychosocial impact of violent war-
like conditions on children remains understudied in Palestine.
Research focused solely on the effect of exposure to traumatic
events on PTSD in the West Bank and Gaza (Abu-Hein,
Qouta, Thabet, & El Sarraj, 1993; Baker, 1990b; Baker, El-
Husseini, Arafat, & Ayyoush, 1991; Barber, 1999, 2001;
Garbarino & Kostelny, 1996; Haj-Yahia, 2004; Herberg &
Övensen, 1993; Punamäki, Qouta, & El Sarraj, 1997, 2001;
Khamis, 1993, 1995, 2000; Qouta, Punamäki, & El Sarraj,
1995, 1998, 2003, 2005; Thabet & Vostanis, 1999; Thabet,
Abed, & Vostanis, 2002).
While the available research has made important contri-
butions to understanding the mental health of children
affected by such conflict, the dominant focus on trauma has
not adequately addressed the practical question of what can be
done to support children affected by violent war-like
conditions. Moreover, an individually focused approach aimed
solely at identifying and treating clinical PTSD in children
cannot adequately address the challenge of improving mental
health outcomes when vast numbers of children and families
are exposed to violent war-like conditions. In this light, even
Psychological reactions to Israeli occupation: Findings from the
national study of school-based screening in Palestine
Ziad Abdeen, Radwan Qasrawi, and Shibli Nabil Mohammad Shaheen
Al-Quds Nutrition and Health Research Institute, Center for Development in Primary Health Care,
Al-Quds University, Jerusalem, Palestine Al-Quds University, Jerusalem, Palestine
Children exposed to violent war-like and repeated political violence often experience a continued
threat to life and their sense of safety, as well as a disruption of daily functioning. The purpose of
the study was to examine the psychological impact of exposure to Israeli occupation on Palestinian
school children in the West Bank and Gaza, Palestine.We assessed the association between exposure
to occupation and the severity of posttraumatic symptoms and the inter-relationship between post-
traumatic symptoms, functional impairment, somatic complaints, and coping strategies in school
children. 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. Results showed that
extensive exposure to violence was associated with higher levels of posttraumatic distress and more
somatic complaints in both the West Bank and Gaza regions. More Gaza than West bank students
reported symptoms meeting the criteria for PTSD, and more girls than boys in both groups reported
somatic complaints. Thus, school-based screening can be an effective method for case identification
of students showing PTSD symptoms as a result of exposure to political violence.
Keywords: adolescents; Israeli; Palestinian; PTSD; trauma; violence
The study was made possible through the generous support of the
Bernard van Leer Foundation, the One-to-One Children’s Fund, the
Andrea and Charles Bronfman Philanthropies and the Al-Quds Nutri-
tion and Health Research Institute at Al-Quds University.
Correspondence should be sent to Ziad Abdeen, Al-Quds Nutrition
and Health Research Institute, Al-Quds University, PO Box 51000,
Jerusalem, Palestine; email: zabdeen@planet.edu
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the definition of post-traumatic stress disorder is problematic
in that it assumes that there is a “post” conflict experience.
However, in the Israeli–Palestinian case, conditions of conflict
have been chronic. Rather than a singular, emotionally charged
event, many of the violent war-like events children face in
Palestine stretch on indefinitely. In the West Bank and Gaza,
entire generations of children have grown up knowing nothing
but violent war-like events and disruption.
To improve the knowledge base available to program design-
ers and policy makers, information on protective processes and
variables associated with better mental health in the face of
war-related stressors merit much more research attention. In
general, there has emerged a resounding need for examining
factors that protect against or moderate the risk of mental
health problems in children exposed to violence (Buka,
Stichick, & Earls, 2001). For the humanitarian community in
particular, there is a need to identify exogenous protective
processes that can be leveraged or enriched by interventions
and policies targeting children and families in emergency
situations (Stichick, 2001). The potentially protective role of
social support and connectedness to others presents one such
promising area of study in the mental health of children
affected by armed conflict.
The attainment of desirable social outcomes and emotional
adjustment, despite exposure to considerable risk, is
commonly referred to as resilience (Luthar, 1993; Rutter,
1985). However, to date little is known about factors
contributing to resilience in the face of war-related stressors
such as violence, displacement, and loss, except that processes
occurring in the families, peers, and the community may
facilitate children’s coping with pervasive threats to their
mental and physical health (Stichick, 2001). Research on these
issues may especially benefit policy-makers in the humanitar-
ian community whose task is to respond to the needs of
children exposed to violence and loss.
Given that school psychologists increasingly deliver services
within a community health perspective (Friedman, 2003;
Strein, Hoagwood, & Cohn, 2003) and intervene when
communities are exposed to traumatic events (Allen et al.,
2002; Motta, 1995; Stein, 1997) they should be familiar with
the effects of trauma on children for screening, diagnosis, and
intervention planning; be members of the response team; use
their knowledge of the local system; provide continued services
following rapid response interventions (Cook-Cottone, 2004);
and consider differential diagnosis and comorbidity of post-
traumatic stress disorder (PTSD) when children are referred
for other symptoms (Ford et al., 2000). However, to date,
despite the frequent exposure of children to beatings, shoot-
ings, arrests, bombings from the air, ground shelling, and
house demolitions (B’Tselem, 2002), the majority of training
programs include merely brief coverage of PTSD and only few
cover in-depth the effects of violent war-like events on
children. Hence, “mapping” of the impact of armed conflict
on children is therefore needed, both as the basis for further
analysis and to assist organizations in devising policies and
programs.
Toward this aim, this paper reports the results of a school-
based screening for posttraumatic distress symptoms and
associated functioning for Palestinian students, conducted in
the academic year of 2004–2005. This was the initial phase of
a comprehensive school-based initiative aimed at determining
the extent and intensity of exposure to violent conflict, and
assessing the ensuing severity of posttraumatic symptoms,
symptoms of hopelessness, and somatic complaints for case
identification of students in need of treatment. Based on a
variety of evidence-based, trauma-focused interventions in
schools (Cohen, Berliner, & Mannarino, 2001; Saltzman,
Pynoos, Layne, Steinberg, & Ainsenberg, 1999; Stein et al.,
2003), Palestinians adapted school-based interventions to
meet the needs of these students.
In sum, this study focuses on evaluating: (1) rates of exposure
to violent conflict among youth; (2) the association between
exposure to violent conflict and the severity of posttraumatic
symptoms in both regions; and (3) the inter-relationship
between posttraumatic symptoms, functional impairment,
somatic complaints, and co-morbidity of hopelessness in the
West Bank and Gaza regions.
Method
Participants
The screening was conducted during the academic year of
2004–2005. A representative sample of 2100 Palestinian
students attending 50 high schools across the Palestinian
Authority was surveyed; 1354 (65%) of the students were from
the West Bank (including East Jerusalem) and 746 (35%) from
the Gaza Strip. Additionally, the sample was stratified by
location of residence (urban, rural, or refugee camp). Students
were in grades 9–11 and ranged from 14 to 17 years of age
(M = 15.9, SD = .99). The gender split was 45% female and
55% male.
Screening instruments
Our instruments consisted of internationally-validated
measures that were translated into Arabic and adapted to the
Palestinian setting.
Self-reported event exposure. To assess exposure to traumatic
events (criterion A1 of PTSD, American Psychiatric Associ-
ation, 2000), participants were asked to respond yes or no to
Haj-Yahia’s 40-item Political Violence Inventory regarding
their exposure to war-like events (Haj-Yahia, 2004). The
higher the score the more reported exposure to traumatic
events.
Emotional reactions to exposure. Criterion A2 of PTSD, i.e.,
subjective exposure accompanied by extreme fear, helpless-
ness, or horror, was assessed with items derived from the
DSM-IV-TR (American Psychiatric Association, 2000) on a
5-point scale. Endorsement of at least one item out of three at
level 4 or 5 was necessary to meet criterion A2, (Cronbach
α = 0.72).
UCLA PTSD Index adolescent version. The adolescent version
of the University of California at Los Angeles Posttraumatic
Stress Disorder (PTSD) scale (unpublished scale by
Rodriguez, Steinberg, & Pynoos, 1999) comprises 22 self-
report items derived from DSM-IV PTSD symptom criteria.
Respondents indicate how frequently they experienced a
symptom during the last four weeks with a 5-point Likert scale
ranging from none (0) to very often (4). The original English
version of this scale was adapted to the Palestinian context by
Abdeen and Qasrawi (2004) (Cronbach α for Arabic Palestin-
ian version = .89).
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Functional Impairment Questionnaire. Functional impairment
was measured by using items that are relevant according to
DSM-IV that were drawn from the Diagnostic Predictive
Scales) (Lucas et al., 2001), and derived from the Child Diag-
nostic Interview Schedule (Shaffer, Fisher, Lucas, Dulcan, &
Schwab-Stone, 2000). The participants were asked to indicate
on a 5-point scale ranging from 1 (not at all) to 5 (very much)
whether they had experienced functional impairment specifi-
cally tied to exposure to political violence, school performance,
family relationships, or after-school activities, during the past
four weeks. A total functional impairment score was computed
as the sum of all items. The internal reliability of the
Functional Impairment Questionnaire was highly satisfactory
(Cronbach’s α = .83). To meet the functional impairment
criterion (F) for PTSD, a respondent was required to have
reported “much” or “very much” impairment in at least one
domain, reflecting clinically significant impairment.
The following three scales were included to assess comorbid
symptoms.
Hopelessness scale for children. This scale consists of 17 yes or
no questions that assess degree of hopelessness (Cronbach
α = .71).
Somatic complaints checklist. These items were based on the
DISC (Shaffer et al., 2000) and drawn from the DPS (Lucas
et al., 2001). This scale consists of seven yes or no items that
assess degree of somatization (Cronbach’s α = .42).
Brief COPE. This scale (Carver, Scheier, & Weintraub,
1989) assesses the use of various coping strategies. Its 14 scales
are subsumed under two overarching scales: emotion-focus and
problem-solving focus coping strategies.
Screening procedure
Screening procedure approved by the Palestinian Authority
Ministry of Education consisted of three steps: (1) Workshops
were carried out for teachers, to help them cope with their own
reactions to the recurrent violence and improve their student
support skills; (2) Screening questionnaires were administered
by the homeroom teacher, with research staff available to
answer questions. Questionnaire administration lasted approx-
imately 30 minutes. Screening was preceded by a letter sent by
school principals, which explained to parents the screening
procedure and requested their consent. (3) Screening was
administered by homeroom teachers supervised by
professional psychologists and included preparation and
debriefing for both students and teachers. Only children
agreeing to participate and permitted to do so by their parents
took part in data collection.
Statistical analysis
Descriptive analysis examined the frequency of exposure to
violence, as well as the relationship between exposure level,
PTSD, and related distress. T-tests and Chi square analyses
explored gender differences in exposure level, PTSD, func-
tional impairment, hopelessness, somatic complaints, and
coping strategies. Chi square and one-way ANOVAs examined
exposure differences in PTSD, functional impairment, hope-
lessness, somatic complaints, and coping strategies. Bivariate
correlations tested the association between coping variables
and the various distress variables.
Results
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.
PTSD Symptoms and self-reported PTSD diagnosis. The
frequency of experiencing PTSD is reported in Table 1.
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. A two-way
(exposure, gender) ANOVA showed no interaction effect; of
the two independent variables only exposure had an effect on
PTSD symptom severity, for WBG = F(3,2099) = 27.89, p <
.001; WB = F(1,1353) = 90.7, p < .001; GZ = F(1,746) =
7.27, p < .001 (see Table 1). Scheffe post-hoc analysis showed
that the groups experiencing both high and medium exposures
reported more PTSD symptoms than the low exposure and
no-exposure groups.
Functional impairment. A two-way (exposure, gender)
ANOVA showed no interaction effect; of the two independent
variables only exposure had an effect on functional impairment
in both regions. Students reporting high exposure also
reported more functional impairment than those students
reporting medium, low or no exposure. WBG = F(3,2079) =
12.56, p < .001; WB = F(3,13429) = 19.34, p < .001; GS =
F(3,737) = 3.04, p < .028 (see Tables 1 and 2).
Exposure and functional impairment. The frequencies and
percentages of functional impairment by exposure levels and
gender are reported in Table 3. Students reporting having
either full or partial PTSD symptoms also reported more func-
tional impairment than did students reporting fewer PTSD
symptoms in all four domains in both regions, including school
performance; family relationships; social relationships; and
extracurricular activities. Chi square analyses revealed signifi-
cant differences by exposure levels in all four domains in both
regions as shown in Table 4.
Somatic complaints. A two-way (exposure, gender) ANOVA
showed no interaction effect but did show effect of exposure
(WBG = F(3,2099) = 50.7, p < .001; WB = F(3,1353) = 41.6,
p < .001; GS = F(3,1353) = 10.95, p < .001) and of gender
(girls higher than boys) (WBG = F(1,2099) = 5.75, p = .017;
WB = F(1,1353) = 27.45, p = .000; GS = F(1,1353) = 2.15,
p = .143). Post-hoc analyses showed that direct exposure and
witnessing direct exposure were associated with more somatic
complaints (see Tables 1 and 2).
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PTSD symptoms and somatic complaints. Students reporting
either full or partial PTSD symptoms also reported experi-
encing at least two somatic complaints significantly more often
than students classified as not having PTSD (WBG = 83% vs.
58%) (2(1, N = 2100) = 158.19, p < .001; WB = 39% vs.
21%), (2(1, N = 1354) = 55.26, p < .001; GS = 40% vs. 21%),
(2(1, N = 746) = 29.87, p < .001.
Co-morbid symptoms. About one third of all participants
(WBG = 32%; WB = 32%; GS = 34%) reported severe
INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 290–297 293
Table 1
Severity of PTS and related distress among Palestinian adolescents by gender and exposure
Functional Somatic
Total PTS impairment Hopelessness complaints
MSD MSD MSD MSD
Total
Exposure categories 28.30 12.98 20.97 7.45 9.84 3.44 2.49 1.71
No exposure 14.64 13.66 16.50 8.27 10.29 4.03 1.00 1.47
Low exposure 25.30 12.54 19.20 7.46 10.55 3.54 1.95 1.55
Medium exposure 29.04 12.70 20.83 7.14 9.86 3.50 2.58 1.67
High exposure 31.19 13.02 23.52 7.18 8.93 2.97 3.07 1.76
Boys 26.27 12.95 22.17 7.60 9.76 2.99 2.40 1.86
Girls 29.96 12.78 19.99 7.18 9.91 3.78 2.57 1.59
West Bank
Exposure categories 27.70 12.90 21.30 7.50 9.80 3.50 2.50 1.70
No exposure 10.50 14.80 26.00 14.1 12.00 5.70 2.50 3.50
Low exposure 24.00 12.80 19.40 7.90 10.40 3.70 1.80 1.60
Medium exposure 28.00 12.30 20.80 7.00 9.90 3.60 2.50 1.70
High exposure 31.00 12.70 23.80 7.30 9.00 3.00 3.10 1.70
Boys 25.80 12.80 22.40 7.60 9.90 2.90 2.30 1.90
Girls 29.30 12.70 20.40 7.30 9.70 3.90 2.60 1.60
Gaza
Exposure categories 29.30 13.20 20.40 7.30 9.90 3.40 2.60 1.70
No exposure 15.30 14.00 14.60 6.10 10.00 4.00 0.80 1.00
Low exposure 26.90 12.00 19.00 6.90 10.70 3.40 2.20 1.50
Medium exposure 31.30 13.20 20.90 7.50 9.70 3.30 2.80 1.60
High exposure 31.60 13.80 22.80 7.00 8.80 2.90 3.10 1.80
Boys 27.10 13.10 21.80 7.50 9.60 3.10 2.60 1.80
Girls 31.20 12.90 19.30 6.90 10.20 3.50 2.60 1.50
Table 2
Mean and (SD) of PTSD symptoms by exposure levels and gender
M (SD)
Category PTSD symptoms Functional PTSD severity
A severity sub-scales impairment score
A1 A2 B C D F PTSD
Exposure Subjective Re- Increased Functional
to trauma fear experiencing Avoidance arousal impairment Severity
MSD MSD MSD MSD MSD MSD M SD
Exposure categories
No exposure 5.21 (5.60) 7.79 (4.19) 4.07 (3.75) 5.86 (6.05) 4.71 (4.50) 16.50 (8.27) (14.64) (13.66)
Low exposure 8.10 (3.74) 9.39 (3.45) 7.02 (4.44) 9.49 (5.58) 8.80 (4.55) 19.20 (7.46) (25.30) (12.54)
Medium exposure 8.26 (3.46) 9.60 (3.39) 8.08 (4.72) 11.04 (5.47) 9.92 (4.66) 20.83 (7.14) (29.04) (12.70)
High exposure 8.40 (3.22) 9.53 (3.36) 8.76 (4.88) 12.35 (5.58) 10.08 (4.50) 23.52 (7.18) (31.19) (13.02)
Gender
Boys 7.35 (3.67) 8.62 (3.23) 6.98 (4.48) 10.76 (5.74) 8.53 (4.53) 22.17 (7.60) (26.27) (12.95)
Girls 8.95 (3.22) 10.23 (3.39) 8.63 (4.79) 10.91 (5.58) 10.42 (4.54) 19.99 (7.18) (29.96) (12.78)
Total 8.23 (3.52) 9.50 (3.41) 7.89 (4.72) 10.84 (5.65) 9.57 (4.63) 16.50 (8.27) (14.64) (13.66)
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symptoms of hopelessness and over one half of them (WBG =
58%; WB = 58%; GS = 59%) reported moderate symptoms
of hopelessness. The rest (WBG = 10%; WB = 11%; GS =
10%) reported mild symptoms of hopelessness.
A two-way (exposure, gender) ANOVA showed an inter-
action effect (WBG = F(3,2099) = 3.07, p = .03; WB =
F(2,1353) = 13.7, p < .0001; GS = F(2,743) = 2.4, p < 0.07;
however, post-hoc tests showed no significant differences
among groups. Both exposure and gender had a main effect on
hopelessness so that direct exposure was associated with higher
hopelessness (WBG = F(3,2099) = 22.56, p < .001; WB =
F(3,1353) = 12.8, p = .002; GS = F(3,745) = 2.24, p = .082
294 ABDEEN ET AL. / PSYCHOLOGICAL REACTIONS TO ISRAELI OCCUPATION
Table 3
Frequencies and percentages of functional impairment domains by exposure levels and gender
After-school More than one
Family Friends School activities impairment
n % n % n % n % n Row N %
West Bank
No exposure 1 50.0 1 50.0 1 50.0 1 50.0 1 50.0
Low exposure 98 26.5 119 32.2 178 48.1 98 26.5 233 63.0
Medium exposure 170 28.1 216 35.6 369 60.9 188 31.0 454 74.9
High exposure 165 43.9 185 49.2 272 72.3 131 34.8 316 84.0
Boys 232 37.9 266 43.5 370 60.5 180 29.4 453 74.0
Girls 202 27.2 255 34.4 450 60.6 238 32.1 551 74.3
Gaza
No exposure 1 8.3 1 8.3 2 16.7 2 16.7 3 25.0
Low exposure 70 23.3 86 28.6 146 48.5 73 24.3 193 64.1
Medium exposure 97 35.4 113 41.2 156 56.9 87 31.8 208 75.9
High exposure 69 43.4 72 45.3 107 67.3 55 34.6 132 83.0
Boys 129 38.4 133 39.6 197 58.6 107 31.8 251 74.7
Girls 108 26.3 139 33.9 214 52.2 110 26.8 285 69.5
Total
No exposure 2 14.3 2 14.3 3 21.4 3 21.4 4 28.6
Low exposure 168 25.0 205 30.6 324 48.3 171 25.5 426 63.5
Medium exposure 267 30.3 329 37.4 525 59.7 275 31.3 662 75.2
High exposure 234 43.7 257 48.0 379 70.8 186 34.8 448 83.7
Boys 361 38.1 399 42.1 567 59.8 287 30.3 704 74.3
Girls 310 26.9 394 34.2 664 57.6 348 30.2 836 72.6
Table 4
Chi square analyses of functional impairment domains by exposure levels and gender
Ye s N o
n % n %
χ
2
P
West Bank
School performance 274 38.8 546 84.4 294.6 .000(*)
Family relationships 159 22.5 275 42.5 62.1 .000(*)
Social relationships 180 25.5 341 52.7 105.9 .000(*)
Extracurricular activities 143 20.2 275 42.5 78.6 .000(*)
Gaza
School performance 141 35.3 270 78.0 137.3 .000(*)
Family relationships 78 19.5 159 46.0 59.9 .000(*)
Social relationships 89 22.3 183 52.9 75.2 .000(*)
Extracurricular activities 79 19.8 138 39.9 36.5 .000(*)
WBG
School performance 415 37.5 816 82.2 430.9 .000(*)
Family relationships 237 21.4 434 43.7 119.7 .000(*)
Social relationships 269 24.3 524 52.8 180.5 .000(*)
Extracurricular activities 222 20.1 413 41.6 115.1 .000(*)
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(see Table 1) and girls reported more hopelessness than boys
(WBG = F(1,2099) = 6.93, p = .009; WB = F(1,1353) = 2.65,
p = .104; GS = F(2,745) = 2.37, p = .124).
Nonetheless, students reporting no PTSD symptoms
reported higher levels of severe hopelessness than others.
PTSD (WBG = 39% vs. 24.4%) (2(1, N = 2100) = 52.77, p <
.001; WB = (38% vs. 24%) (2(1, N = 1354) = 32.4, p < .001;
GS = (41% vs.25.1%) (2(1, N = 746) = 20.27, p < .001) and
lower levels of moderate (WBG = 54% vs. 62%) (2(1, N =
2100) = 13.35, p < .001;WB = (55% vs.61%) (2(1, N = 1354) =
4.96 p < .001; GS = (53% vs. 64%) (2(1, N = 746) = 9.83
p = .002) and mild hopelessness (WBG = 7% vs. 14%) (2(1,
N = 2100) = 27.45, p < .001; WB = (7% vs. 16%) (2(1, N =
1354) = 24.1, p < .001; GS = (7% vs. 11%) (2(1, N = 746) =
4.18, p < .041. While these results may suggest that hopeless-
ness is an alternative reaction to stress, the exploratory nature
of this study requires caution and replications.
Coping strategies and PTSD diagnosis. The most frequently
used coping strategies among the students were accepting the
reality 2.21 (.72), religion 2.20 (.77), and distraction 1.88
(.84) (see Table 5). The extent to which each of these coping
strategies moderated the relation between posttraumatic
symptoms and the level of somatic complaints was examined
by multiple regression analysis. Significant interactions were
found between seeking instrumental help and posttraumatic
symptoms and between seeking emotional help and post-
traumatic symptoms. These interactions indicate stronger
relation between posttraumatic symptoms and somatic
complaints for participants seeking more emotional help and
weaker relation between posttraumatic symptoms and somatic
complaints for participants seeking more instrumental help.
Despite high levels of exposure, resilience was evidenced, as
more than half of the students sampled had few or no
symptoms of distress. The high rates at which youth used
coping mechanisms is curious considering the preponderance
of PTSD and related distress. This finding may suggest that
self-report of coping mechanisms may actually reflect higher
levels of stress and not necessarily the success of coping mech-
anisms in mitigating stress. Highly adaptive methods of coping
were reported as being used by nearly the entire sample.
Although more maladaptive methods of coping were also
endorsed at high rates, these numbers are less alarming when
noting that all coping methods were endorsed at high rates, and
that adaptive methods were used with even greater frequency.
Discussion
Almost all participants reported direct exposure to political
violence either by being present at the scene or by witnessing
events. Boys reported more direct exposure whereas girls
reported more witnessing. These gender differences reflect the
higher tendency in Palestinian society for boys to be actively
involved in events, and for girls to act as bystanders.
Direct exposure was associated with more PTSD. No gender
difference was found on the total Palestinian population
although an interaction effect revealed that boys being directly
exposed reported more sever PTSD than girls while girls
witnessing direct exposure report more PTSD than boys. In
addition, no gender difference was found in the severity of
functional impairment and no association was found between
exposure level and the severity of functional impairment.
Adolescents reported on high levels of functional impairment
in all domains. Adolescents reporting full or partial PTSD
reported much more severe functional impairment in all
domains of functioning than did others.
Somatic complaints were associated with both exposure level
as well as meeting criteria for full or partial PTSD but not with
gender.
Two coping strategies were found to moderate the relation-
ship between posttraumatic symptoms and somatic complaints,
though in opposite directions: seeking emotional and instru-
mental help. Specifically, adolescents seeking more emotional
help have a stronger association between posttraumatic distress
and somatic complaints, and adolescents seeking more instru-
mental help have a weaker association between posttraumatic
symptoms and somatic complains.
Girls reported higher levels of hopelessness and somatic
complaints than boys. Additionally, the severity of their hope-
lessness was lower among girls who reported high exposure
than medium or low exposure categories. In addition, girls who
reported high exposure also reported more somatic complaints
than the other three exposure groups, and those who reported
medium exposure also reported more somatic complaints than
those who reported low or no exposure.
In all, our findings on adolescents’ reaction to exposure to
political violence are consistent with earlier studies conducted
in the Palestinian Authority and elsewhere (Schwarzwald,
Matisyhu, Waysman, Solomon, & Klingman, 1993; Shaw,
2003; Thabet et al., 2002), as are our results about girls’
INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 290–297 295
Table 5
Moderated regression analysis of posttraumatic symptoms and
coping strategies on somatic complaints among Palestinian
adolescents
β
T
Posttraumatic symptoms (PTS) .179 1.497
Distraction .088 .809
Active coping .045 .417
Denial .002 .020
Getting instrumental help –.130 -.998
Getting emotional help .052 .403
Disengagement –.087 -.897
Venting –.081 -.821
Reframing –.091 -.873
Planning .052 .502
Humor .200 2.534*
Accepting reality .021 .290
Religion –.025 -.306
Guilt .007 .076
PTS * Distraction .046 .303
PTS * Active coping –.146 –1.072
PTS * Denial .006 .045
PTS * Getting instrumental help .221 1.275
PTS * Getting emotional help .014 .082
PTS * Disengagement .203 1.684
PTS * Venting .029 .243
PTS * Reframing .203 1.619
PTS * Planning –.082 –.641
PTS * Humor –.181 –1.872
PTS * Accepting reality .079 .663
PTS * Religion .126 1.186
PTS * Guilt –.022 –.175
Note. R
2
= .243; F(27,1224) = 14.195; p < .001; *p < .05; **p < .01.
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higher tendency to report co-morbid distress (Brent et al.,
1995; Dyregrov, Gjestad, & Raundalen, 2002; Pfefferbaum et
al., 2000, 2003). From yet another perspective, our findings
showed more reports of depressive symptoms than the 3 to 8%
found among normal adolescents (Brent et al., 1995). Finally,
functional impairment was most prominent within the school
domain which thus highlights the need to develop appropriate
school-based interventions for the prevention and treatment of
affected students. Trauma exposure results in a broad spectrum
of psychological sequelae beyond posttraumatic symptoms.
Limitations
We are aware of three main limitations in the design of this
study: data were collected from only one source (adolescents),
at only one time point (cross-sectional) and in one setting.
Consequently, future research could be strengthened by
collecting information from multiple sources, including
parents and teachers, at more than one time point and in
several settings suffering political violence.
Conclusion
High levels of school distress suggest that impairment of func-
tioning at school is a sensitive indicator of more global distress,
perhaps because school failure is more easily recognizable and
quantifiable than impairment in other domains (e.g., family).
Thus, functioning at school may be a key tool in identifying
youth in need. High-risk students seem to be those affected by
more intensive exposure to violence, girls, and those reporting
depressive symptoms.
School-based intervention is the best way to reach a large
number of children suffering from conflict-related distress
and to target youth in their natural school environment by
training professionals in the educational system. School-based
programs allow youth to be trained and treated in a non-
stigmatizing environment with little disruption to their daily
schedules, which is important for mitigating posttraumatic
stress. Prevention and intervention efforts are not only crucial
for the immediate relief of suffering, but also for preventing
and mitigating the long-term effects of untreated mental
distress on youth growing up in the shadow of political
violence.
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