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British Journal of Education, Society &
Behavioural Science
11(1): 1-13, 2015, Article no.BJESBS.19101
ISSN: 2278-0998
SCIENCEDOMAIN international
www.sciencedomain.org
Trauma, PTSD, Anxiety, and Resilience in
Palestinian Children in the Gaza Strip
Abdelaziz Mousa Thabet
1*
and Sanaa S. Thabet
2
1
Child and Adolescent Psychiatry, School of Public Health-Child Institute-Gaza- Al Quds University,
P.O.Box 5314, Palestine.
2
Child and Family Training and Counseling Center-NGO, Palestine.
Authors’ contributions
This work was carried out in collaboration between both authors. Authors AMT designed the study
and wrote the protocol. Author SST preformed the data collection and statistical analysis, managed
the literature search. Author AMT wrote the first draft of the manuscript with assistance from author.
Both authors read and approved the final manuscript.
Article Information
DOI: 10.9734/BJESBS/2015/19101
Editor(s):
(1)
William Jankowiak, Department of Anthropology, University of Nevada,
USA.
Reviewers:
(1)
Anonymous, USA.
(2)
Prakash I. Mehta, Department of Psychiatry, Gujarat University, Gujarat, India.
(3)
Andrew Chih Wei Huang, Department of Psychology, Fo Guang University, Taiwan.
(4)
Muhammad Kristiawan, Muhammadiyah University of West Sumatera, Indonesia.
Complete Peer review History:
http://sciencedomain.org/review-history/10267
Received 25
th
May 2015
Accepted 10
th
July 2015
Published 21
st
July 2015
ABSTRACT
Aims:
The aim of the study was to investigate the effect of traumatic events due to eight days of
military escalation on children PTSD, anxiety, resilience, relationship of between children mental
health problems and resilience.
Methods: This was descriptive analytic study. The study sample consisted of 502 randomly
selected children from 16 districts of the Gaza Strip. Age ranged from 9 to 16 years. Children were
assessed by a socio demographic questionnaire, Gaza Traumatic Events Checklist, Post traumatic
stress disorder scale, Children’s Revised Manifest Anxiety Scale, and Resilience Scale for
Adolescents.
Results: Children reported commonly traumatic events such as hearing the loud voice of Drones
(98.8%), hearing shelling of the area by artillery (98.6%), hearing the sonic sounds of the jetfighters
Original Research Article
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
2
(98.4%), and watching mutilated bodies of Palestinians in TV (98.2%). Mean traumatic events
reported by children was 7 events. Boys reported severe traumatic events than girls; traumatic
events were reported in children living in a city than in village and camp.
This study showed that 35.9% of children showed full criteria of PTSD. Post traumatic stress
disorder and re-experiencing symptoms were more in girls. Also, children coming from families with
family income less than $300 and living in city.
The children anxiety symptoms, 30.9% of children had anxiety disorder. No differences in anxiety
disorder between boys and girls. Anxiety was more in children living in camps and family monthly
income less than $300.
Palestinians children used different ways of coping with the stress and trauma, and common
resilience items were 94.6% said they were proud of their citizenship, 92.4% said they feel safe
when they were with their caregivers, 91.4% said that their spiritual (religious) beliefs were a source
of strength for them, and 91% said they were proud of their family background.
Total resilience in children, personal skills, peer component, and social skills, contextual
components that facilitate a sense of belonging (Spiritual beliefs, culture, and educational items)
were more in of girls. Total resilience and contextual components were more in children living in a
camps and a village than in a city. However, there were statistically significant differences in
individual factors (personal skills, peer component, and social skills) were more in children from
family monthly income $301-750 than families with monthly income of 300$ and less. Also,
traumatic events were correlated positively with anxiety and PSTD and negatively correlated with
total resilience factor.
Conclusion: This study showed that the last war on Gaza had negative impact on children mental
health and resilience. Children were a particularly vulnerable target group. Trauma due to war
increased children psychological symptoms, including post-traumatic stress disorder and anxiety.
Such psychological problems were associated with traumatic experiences, and trauma decrease
children resilience.
Keywords: Anxiety; children; Gaza strip; PTSD; resilience; trauma.
1. INTRODUCTION
The Gaza Strip is a narrow elongated piece of
land, bordering the Mediterranean Sea between
Israel and Egypt, and covers 360 km
2
. It has
high population density. About 17%
of the
population lives in the north of the Gaza Strip,
51% in the middle, and 32% in the south area.
There is high unemployment, socioeconomic
deprivation, family overcrowding, and short life
expectancy. Nearly two-thirds of the populations
are refugees, with approximately 55% living in
eight crowded refugee camps. The remainder
lives in villages and towns. During the Palistinian-
Isreali conflict the latest cumulative casualty
figures reported by the Ministry of Health in Gaza
were 175 killed persons (151 males; 24 females)
of whom 43 (25%) were children; 16 children
were less than 5 years old. The total includes 5
persons who had later died of their injuries, and
1399 persons injured, of whom 431 (34%) were
children and 141 were less than 5 years old.
(Earlier MoH data with gender disaggregation
was based on uncorrected figures of 1404
injured (994 males; 410 females) [1].
In studies of Palestinian children in the Gaza
Strip found that children experienced variety of
traumatic events including witnessing killing of
relatives, demolition of homes, bombardment,
and arrest of relatives was associated with post
traumatic disorder, anxiety, and depression.
They severely deteriorate children’s sleep and
cause uncontrollable fears among babies and
children, causing anxiety, panic attacks, and poor
concentration [2,3,4]. In another study, others
found that military trauma in middle childhood
and stressful life-events in early adolescence
formed a risk for post traumatic stress disorder
and depressive and decreased satisfaction with
the quality of life in adolescence [5].
Others, in a study on the experiences of
Palestinian children (aged 1–15) residing in the
West Bank, witnessing traumatic events such as
murder, physical abuse, destruction of property,
and threats was associated with PTSD
symptoms [6]. Moreover, in another study of a
sample of 600 Palestinian youths (8-14 years
old) in West Bank and Gaza Strip found that
children exposed to a variety of political conflict
and violence (73%) witnessed actual political
violence and (99%) witnessed political violence
through media reports. A significant predictor of
post traumatic stress symptoms was exposure to
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
3
political conflict and violence. Gender and age
also did not interact with exposure to political
violence when predicting PTS symptoms with
other types of exposure [7]. In another area of
war and conflict in Asia, researcher found a high
number of somatic complaints and memory
problems among children (aged 10–14) exposed
to war in Sri Lanka [8]. While, in study of Kuwati
children, showed that there was an association
between exposure to war-related trauma and
poor subjective ratings of health and sleep
quality among children aged 9 to 12 living in
Kuwait [9].
Resilience refers to positive patterns of
functioning during or following an adverse event.
According to this definition, an individual must be
functioning at an adaptive level consistent with
standards appropriate for one’s age and
developmental level following exposure to an
adversity [10]. Others have defined resilience as
the capacity of individuals to successfully
maintain or regain their mental health in the face
of significant adversity or risk. Resilience is an
interactive dynamic construct that considers
protective factors and positive adaptation in
adversity, rather than focusing on risk factors and
psychopathology [11]. Spirituality was commonly
reported to be important to resilience and
adaptive in illnesses. It was postulated that belief
in God or having faith helped individuals make
sense of the illness and acted as a source of
strength. Participants high in spirituality were
reported to have better mental health and
adjustment [12,13,14]. However, it should be
noted that within the trauma literature resilience
is also frequently defined as a lack of
psychopathology (i.e., posttraumatic stress
disorder, anxiety, depression) [15].
Studies that have specifically focused on the
resilience of children exposed to community
violence have identified social support from a
child’s family (parent), school, and peer group to
be important in resilience from repeated violence
exposure [16,17]. Family cohesion and positive
coping on the part of parents also appear to
lessen the negative impact of community
violence [18,19]. Studies of people living in
war zones highlight the significance of
interdependent coping, confirming that the level
of emotional upset and anxiety displayed by
parents, not the war itself, is the most important
factor in predicting a child’s response [20].
Others found that specific aspects of social
support within the children’s family (e.g.,
perceived parental helpfulness) and school (e.g.,
teacher helpfulness) provided some level of
protection against the deleterious influence of
community violence exposure [21]. According to
others, community resilience emerges from
community-level resources that enhance
residents’ abilities to adapt in positive ways to
risk. Social capital resources, institutional
resources, and economic resources are three
types of resources that contribute to community
resilience. The aim of the study was to
investigate the effect of traumatic events due to
eight days of military escalation on children
PTSD, anxiety, resilience, relationship of
between children mental health problems and
resilience [22].
2. METHODS
2.1 Participants
The target population consisted of 502 children
ages 9 to 16 years, who were exposed to the war
on the Gaza Strip on November 2012, and who
lived in five localities of the Gaza Strip (north
Gaza, Gaza, Middle area, Khan Younis, and
Rafah area). They were 250 boys (50 %) and
250 girls (50%). Mean age of 12.57 years (SD =
2.2).
2.2 Study Procedure
Data collection was conducted by 10
professionals who attended day training by the
principal investigator about the aim of the study,
sample, and questionnaires of the study. Data
collection was done from 1
st
January one-day 26
January 2013 which include the 502 children in
the five areas. For selecting the children from
each district, one street was selected in each
area, and every principal was selected. In larger
buildings, one flat from each floor was selected
randomly. Families were included if they
consisted of both parents, with one boy or one
girl, aged between 9-16 years, and had been in
the area for the last year. Families were
approached until 502 agreed to let their children
participate. Covering letter was given to each
participant explaining the aim of the study and
about their right not to participate in study and
ask them to sign the letter. With the family
member lasted for 30 minutes.
2.3 Measures
2.3.1 Socio-demographic questionnaire
The researcher prepared a questionnaire which
included; name, gender, date of birth, place of
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
4
residence, number of siblings, and other
demographic information.
2.3.2 Gaza traumatic events checklist
The checklist was developed to reflect the
particular circumstances of the regional
conflict which could not be captured by other
war trauma measures and had been reported
previously [2,3,4]. This checklist consisted of
18 items covering three domains of events
typical of the war on Gaza: (1) hearing traumatic
events (items number 1-5 include hearing about
killing of relatives or friends) (2) witnessing
trauma (items number 6-12, experiencing
witnessing of home demolition, killing of others);
and (3) personal experiences (items number
13-18, being personally the target of violence,
being shot, injured, or beaten up by soldiers).
The respondents rated their answer whether
they had been exposed to each of these events
as (0) ‘no’ or (1) ‘yes’. A total score was
estimated. In this study, the split half reliability of
the scale was high (r = .59). The internal
consistency of the scale was calculated using
Chronbach’s alpha was high ( = .64).
2.3.3 UCLA PTSD index for DSM-IV:
Adolescent version [23]
The items of the UCLA PTSD indices are keyed
to DSM-IV criteria and can provide preliminary
PTSD diagnostic information. Self-reports for
children and adolescents exist, as well as a
parent report of PTSD symptoms. The
adolescent Version (for adolescent aged 13
years and older) contains a total of 22 questions,
have also been administered in school classroom
settings. A 5-point Likert scale from 0 (none of
the time) to 4 (most all the time) is used to rate
PTSD symptoms. Only 17 items were included in
the total score because two items were not DSM-
IV criteria and three items were repeated
symptoms. The split-half reliability of this
measure was 0.60 and the Cronbach alpha was
( = .71).
2.3.4 The revised children’s manifest anxiety
scale (RCMAS) [24,25]
The Revised Children’s Manifest Anxiety Scale is
designed to measure symptoms of generalized
anxiety in children and youth. The 37 scale items
are answered yes or no. Nine items comprise a
Lie scale, thus symptom severity scores range
from 0–28. The clinical cutoff score is ≥ 18.
Reliability Kuder-Richardson- 20 (KR-20) has
been found to be high =.85. [26]. A high
correlation (r = .85) has been found between RC-
MAS and other instruments measuring trait
anxiety (Reynolds, 1980). In the present
population, the KR-20 for the RCMAS was
( = .87).
2.3.5 Resilience scale for adolescents [11]
The scale is a 28-item self-report scale using
positively phrased. Higher scores reflect higher
degree of resilience. This scale was developed
using confirmatory factor analysis and has shown
adequate psychometric properties (total
Chronbach alpha = 0.94) and initial promising
validity [11]. Results suggest that the Resilience
Scale for Adolescents has three subscales
reflecting the major categories of resilience.
Furthermore, each subscale has its own
groupings of questions that serve as indicators of
the construct’s major categories. The first
subscale reflects an individual factor that
includes personal skills (5 items), peer support (2
items), and social skills (4 items). The second
subscale deals with caregiving, as reflected in
physical caregiving (2 items) as well as
psychological caregiving (5 items). The third
subscale comprises contextual components that
facilitate a sense of belonging in youth,
components related to spirituality (3 items),
culture (5 items), and education (2 items). The
split-half reliability of this measure was 0.70 and
the Cronbach alpha was ( = .83).
2.4 Statistical Analysis
Data entry and analysis were carried out using a
statistical software SPSS version 18.0 (SPSS
Inc. Chicago Ill, US). Frequency and percent
were used to express quantitative data of types
of trauma, mental health disorder, PTSD,
anxiety, and resilience. For continuous variables
means and standard deviations were reported.
For differences between means of two groups
parametric tests were used such as an
independent t-test was conducted to compare
gender of children and mean of trauma, PTSD,
anxiety, and resilience. While, One Way ANOVA
test was used for measuring differences between
more than two groups of continuous variables
total traumatic events, PTSD, anxiety, resilience,
and other sociodemographic variables.
Spearman’s correlation coefficient was used to
test the association between numbers of
traumatic experiences, PTSD, anxiety, and
resilience. Logistic regression analysis was
conducted in which PTSD/no PTSD was entered
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
5
as dependent variable and each traumatic events
as independent variables. Another Multivariate
regression analysis was conducted, in which
each traumatic events were entered as the
independent variables, and PTSD, Anxiety,
Resilience entered as the dependent variable.
We used an alpha level of .05 for all statistical
tests.
3. RESULTS
3.1 Sociodemographic Characteristics of
the Children and Adolescents
The sample consisted of 251 boys (50 %) and
251 girls (50%) (Table 1). According to the
selection criteria, the age range was 9-16 years,
with a mean age of 12.57 years (SD = 2.2).
Regard place of residence, 94 of children were
from north Gaza (18.9%), 174 live in Gaza area
(34.7%), 84 live in Middle area (16.7%), 96 live in
Khan Younis and East area (19.1%), and 54 live
in Rafah area (10.8%). Regard place of
residence, 262 of children personal competence,
control, trust in one's instincts in urban areas
(52.2%), 173 in camps (34.5%), and 67 in a rural
area (13.3%). Families were of large size, as
22.1% of the participating families had 4 or less
siblings, 49.8% had 5-7 siblings and 28.1% of
had 8 or more siblings. Regard family monthly
income, 67.1% of the families had a monthly
income under $300, 25.7% between $301-751,
5.4% had a monthly income above $751-1000,
and 1.8% had more than $1001.
3.2 Exposure to Traumatic Events
As shown in Table 2, the highest frequencies of
reported traumatic events were hearing the loud
voice of Drones’ motors (98.8%), hearing shelling
of the area by artillery (98.6%), hearing the sonic
sounds of the jetfighters (98.4%), and watching
mutilated bodies in TV (98.2%). Palestinian
children reported 3-17 traumatic events with a
mean= 7.5 traumatic events (SD = 2.28).
3.2.1 Severity of traumatic events due to war
on Gaza
In order to find the severity of the traumatic
experiences, total traumatic events were
recorded in to mild trauma (0-5 events),
moderate trauma (6-10 events) and severe
trauma (above 11 events). The results showed
that 6.6% reported mild traumatic events, 67.7%
reported moderate traumatic events, and 25.7%
reported severe traumatic events. Chi square
test showed that 11.6% of boys reported severe,
and 8.4% of girls reported severe traumatic
events. Boys statistically significantly reported
severe traumatic events than girls (2 = 15.23, df
=1. p = 0.001).
Table 1. Sociodemographic information of the
children (N =502)
Gender
No.
%
Male 251 50
Female 251 50
Age Mean = 12.57 (SD = 2.2)
Place of residence
North Gaza 94 18.7
Gaza 174 34.7
Middle area 84 16.7
Khan Younis 96 19.1
Rafah 54 10.8
Type of residence
City 262 52.2
Village 67 13.3
Camp 173 34.5
No of siblings
Four and less
111
22.1
Five to seven siblings 250 49.8
Eight and more siblings 141 28.1
Family monthly income
Less than $300 337 67.1
$301-750 129 25.7
$751-1000 27 5.4
More than $1001 9 1.8
3.2.2 Differences in children reporting
traumatic events according to other
sociodemographic variables
In order to find differences in total traumatic
event and other sociodemographic variables
such as gender, age, place of residence,
education, family monthly income an
independent-samples t-test for less than two
groups and One Way ANOVA for more than
three groups were conducted.
Mean traumatic event reported by boys were
7.84 (SD =2.30) and 7.19 reported by girls (SD =
2.24). There was significantly reporting traumatic
experiences more in boys than in girls (t (500)=
3.23, p < 0.01).
Age of children was recorded in to two groups (9-
12, and 13-16 years). Independent-samples t-
test was done, mean traumatic events
experienced by children age 9-12 years was 7.57
(SD =2.45) and mean for children age 13-16
years as 7.46 (SD = 2.12). There was no
significant differences in reporting traumatic
experiences according children age group (t
(500)=.53, p < 0.01).
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
6
Table 2. Percentage of traumatic experiences by children (N= 502)
Trauma
Yes
No
No.
%
No.
%
Hearing the loud voice of Drones’ motors 496 98.8 6 1.2
Hearing shelling of the area by artillery 495 98.6 7 1.4
Hearing the sonic sounds of the jetfighters 494 98.4 8 1.6
Watching mutilated bodies of in TV
493
98.2
9
1.8
Witnessing the signs of shelling on the ground 398 79.3 104 20.7
Receiving threaten letters by the Israeli army through local
Television or the Radio
279 55.6 223 44.4
Unable to leave you home with family members due to fears
of shelling in the street
270 53.8 232 46.2
Hearing killing of a friend 175 34.9 327 65.1
Witnessing firing by tanks and heavy artillery at neighbors'
homes
143 28.5 359 71.5
Receiving pamphlets from air planes to leave your home at
the border and to move to the city centers
137 27.3 365 72.7
Threaten by telephoned to evacuate your home before
bombardment
79 15.7 423 84.3
Witnessing assassination of people by rockets 75 14.9 427 85.1
Forced to leave you home with family members due to
shelling
75 14.9 427 85.1
Witnessing shooting of a friend 65 12.9 437 87.1
Hearing killing of a close relative
50
10
452
90
Witnessing firing by tanks and heavy artillery at own home 18 3.6 484 96.4
Witnessing shooting of a close relative 18 3.6 484 96.4
Physical injury due to bombardment of your home 14 2.8 488 97.2
Fig. 1. Severity of traumatic events in children due to 8 days war on Gaza in children (N= 502)
One-way ANOVA was conducted in which total
traumatic events was entered as dependent
variable and other sociodemographic variables
as independent variables. Post hoc analyses
using Tukey’s HSD showed that mean traumatic
events for children's' place of residence (city,
village, and camp) was (9.36, 7.69, and 8.63
respectively). There was significantly more
experiences of traumatic events in children living
in city than in village or camp, F(2, 499) = 9.34, p
= 0.01). There were no statistically significant
differences in traumatic events according to
11.2
77.3
11.6
24.3
67.3
8.4
0
10
20
30
40
50
60
70
80
90
MildModerateSevere
Male
Female
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
7
families monthly income, F(2,499)= 2.407, p =
.59.
3.2.3 Post traumatic distress reactions in
children and adolescents
Children commonly reported post traumatic
stress disorder symptoms such as 50.8% of
children said that they had exaggerated startle
response, 37.6% had acting or feeling as if the
traumatic event were recurring, 37.6% had
intense psychological distress at exposure to
internal or external cues that symbolize or
resemble an aspect of the traumatic event,
36.9% doing efforts to avoid thoughts, feelings,
or conversations associated with the trauma.
While, the least common reactions symptoms
were: 10% said that they had restricted range of
affect (e.g., unable to have loving feelings), and
11% said they had feeling of detachment or
estrangement from others.
3.2.3.1 Prevalence of PTSD
Using DSM-TR diagnostic criteria for PTSD of
summing of (one reexperiencing, 3 avoidance,
and 2 arousal symptoms), the study results
showed that 31 of children (6%) showed no
PTSD, 136 of children (27%) showed at least
one criteria of PTSD (B or C or D), 31% showed
PTSD and 36% of children showed full criteria of
PTSD.
3.2.3.2 Means and standard deviations of PTSD
The results showed mean total scores of PTSD
was 26.93 (SD =12.71), mean reexperiencing
symptoms was 9.43 (SD =4.72) mean avoidance
was 9.02 (SD= 5.49), and mean arousal was
8.47 (SD = 4.96). There was significantly more
PTSD in girls than boys (M= 28.20 girls vs. 25.68
boys) (t (500)= 2.22, p< 0.02), and also for
reexperiencing symptoms which were
significantly more in girls than boys (Mean =
10.10 for girls vs. 8.77 for boys) (t (500)= 3.19, p
< 0.002). Independent-samples-t test showed
that there no significant differences in total PTSD
according to age group of children (9-12, 13-16
years) (M = 37.78 vs. 26.13) (t(500) = 1.45, p <
0.14).
3.2.3.3 Differences in PTSD according to other
sociodemographic variables such as
type of residence, and family monthly
income
Analysis of variance showed a main effect of
place of residence on
PTSD. Post hoc analyses using Tukey’s HSD
indicated that children living in city were higher in
PTSD than for children living in village or camp,
F(2, 499) = 6.73, p = .001. Also, total PSTD was
higher in children coming from families with
family monthly income less than $300, F(3) 499
= 6.01, p = 0.003).
Fig. 2. Prevalence of PTSD (N = 502)
6
27
31
36
0
5
10
15
20
25
30
35
40
No PTSDOne criteria of PTSD Partial PTSDPTSD
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
8
3.2.3.4 Relationship between PTSD and total
trauma
Pearson correlation test was done to find the
relationship between PTSD and trauma.
Correlations are reported with the degrees of
freedom (which is N-2), total traumatic events
reported by children were strongly correlated with
total PTSD (r (502)= 0.19, p < 0.001),
reexperiencing (r (502)=0.19, p < 0.001),
avoidance (r (502) =0.16, p < 0.001), and
arousal symptoms (r (502)=0.13, p < 0.01).
3.2.4 Prediction of PTSD by types of
traumatic events
In order to test the predictive value of specific
traumatic events on PTSD symptoms, PTSD
(yes/no) were entered as the dependent variable
in a logistic regression analysis, with the 18 types
of traumatic events as the covariates. Traumatic
events that significantly predicted children post-
traumatic stress disorder were: forced to leave
home with family members due to shelling (β
=0.12, p< 0.01), receiving pamphlets from air
planes to leave home at the border and to move
to the city centers (β=0.13, p< 0.01), and
receiving threaten letters by the Israeli army
through local Television or Radio (β = 0.10, p<
0.03).
3.3 Anxiety Disorder Symptoms in
Children
The children anxiety symptoms were rated
according to Revised Child Manifest Anxiety
scale. The most common anxiety symptoms
reported by children were: Others seem to do
things easier than I can (81.3%), other children
are happier than me (71.7%), and I get nervous
when things do not go the right way for me
(64.3%).
3.3.1 Prevalence of anxiety disorder in
children
We used cut of point of 18 and above as
indicator of presence of anxiety in children. The
result showed that 155 children had anxiety
disorder (31%) and 347 children (69%) had no
anxiety disorder and. According to gender of
children, 76 of boys (15.2%) had anxiety disorder
and 79 of girls (15.8%) had anxiety disorder. Chi-
square test of independence was performed to
examine the relation between gender and
anxiety. There were no significant differences in
anxiety disorder according to children gender, 2
(1, N = 502) = 0.08, p <.77.
3.3.2 Means and standard deviations of
anxiety according to sociodemographic
variables of children
The results showed that mean anxiety in boys
was 14.24 (SD = 6.76) and mean anxiety in girls
was 13.89 (SD = 6.07). No statistically significant
differences in anxiety disorder according to
gender of children (t (500)= .67, p < 0.44). The
results showed no significant differences in total
anxiety scores according to age group of children
(9-12, 13-16) (t(500) = 1.71, p < 0.35). Post hoc
analyses using Tukey’s HSD indicated that
anxiety was higher in children living in camps
than in city and village (F (2, 499) = 4.78, p =
0.01). Anxiety was higher in children coming
from families with family monthly income less
than $300 (F(2, 499) = 5.9, p = .003).
3.4 Resilience in Children and
Adolescents
3.4.1 Frequency of resilience items
According to the children report of the most
common resilience items were: 94.6% said they
were proud of their citizenship 92.4% said they
feel safe when they were with their caregivers,
91.4% said that their spiritual (religious) beliefs
were a source of strength for them, and 91% said
they were proud of their family background.
3.4.2 Means and standard deviations of
resilience according to
sociodemographic variables of children
3.4.2.1 Gender of children and resilience
The results showed that mean total resilience in
boys was 114.69 (SD =14.75) and mean
resilience in girls was 117.76 (SD = 12.94).
Mean personal skills for boys was 19.07 and
19.63 for girls, mean peer component for boys
was 7.23 and 7.81 for girls, social skills for boys
was 15.35 and 15.75 for girls, relationship with
caregiver for boys was 29.98 and 30.20 for girls,
spiritual (religious) beliefs for boys was 12.71
and 13.08 for girls, culture factor for boys was
21.59 and 21.80 for girls, and educational items
for boys was 8.74 and 9.50 for girls. Girls were
significantly reported more resilience than boys
(t(500) = 2.48, p < 0.01). This was applicable for
subscales of resilience, girls reported more
peer component (t (500) = 2.69, p <0.01), and
educational factor than boys (t (500)= 4.51, p <
0.001).
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
9
Table 3. Means and standard deviations of resilience factors according to gender of children
(N = 502)
Gender
Mean
SD
t
p
Total resilience in children Male 114.7 14.75 -2.48 .01
Female 117.8 12.94
Personal skills Male 19.07 3.71 -1.64 .10
Female 19.63 3.89
Peer component Male 7.23 2.61 -2.69 .01
Female 7.81 2.24
Social skills Male 15.37 3.48 -1.26 .21
Female 15.75 3.17
Relationship with caregiver Male 29.98 4.97 -.52 .60
Female 30.20 4.45
Spiritual (religious) beliefs Male 12.71 2.27 -1.89 .06
Female 13.08 2.08
Culture factor Male 21.59 3.49 -.74 .46
Female 21.80 3.02
Educational factor Male 8.74 2.28 -4.51 .001
Female 9.50 1.37
3.4.3 Differences in resilience factors
according to other sociodemographic
variables of children
The results showed no significant differences in
total resilience scores and subscales according
to age group of children (9-12, 13-16) (t(500) =
.33, p <0.37).
Post hoc analyses using Tukey’s HSD indicated
that total resilience scores, F (2,499) =9.62, p =
0.01, and contextual components, F
(2,499)=10.85, p = 0.01 was higher in children
living in camps and village than in city. Also there
were significant differences in individual factor
toward children living in a camp than in a city, F
(2,499)= 4.69, p = 0.01), and relationship with
caregiver were more in children live in a village
than in a city, F (2,499)= 5.58, p = 0.01). There
were no significant differences in total resilience,
relationship with caregiver, and contextual
components according to family monthly income.
However, there were statistically significant
differences in individual factor toward children
from family monthly income $301-750 than
families with monthly income of $300 and less, F
(2,499)= 4.93, p = .01). There were no significant
differences in total resilience and three factors
scores according to father education. There were
significant differences in total resilience, F
(2,499)= 4.26, p = 0.01), and individual factor
toward mothers with university education than
less than elementary education group, F (2,499)
= 6.70, p = .01).
3.4.4 Relationships between traumatic
events, security, anxiety, PTSD
symptoms, and total resilience of
children
Pearson correlation test was done to find the
relationship between traumatic events, anxiety,
PTSD symptoms, and total resilience.
Correlations are reported with the degrees of
freedom (which is N-2), Total traumatic events
reported by children were negatively strongly
correlated with total resilience in children (r
(502)= - 0.13, p=0.001), peer component (r
(502)= - 0.10, p=0.001), and relationship with
caregiver (r (502)= - 0.13, p=0.001). However,
traumatic experiences by children were positively
correlated with PTSD (r (502)= 0.19, p =0.001)
and anxiety (r (502)= 0.29, p=0.001).
Table 4. Pearson rank correlation coefficient:
traumatic events, anxiety, PTSD, and
resilience
Traumatic events
Total PTSD .19**
Total Anxiety .29**
Total resilience in children -.13**
Personal skills -.09
Peer component -.10 *
Social skills -.06
Relationship with caregiver
-.13**
Spiritual (religious) beliefs -.05
Culture -.05
Education -.05
*p<0.05, **p<0.01, **p< 0.001
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
10
4. DISCUSSION
This study showed that mean traumatic events
experienced by each Palestinian children was 7
events. Children living in city and being boys
were more traumatized. Such findings may be
explained by cultural factors because boys are
more free to move outside the home and girls are
kept at homes and being in city was another risk
factors in which major cities were exposed more
to bombardment than villages and refugee
camps. Others found similar results; girls
generally showed increased vulnerability for
PTSD following exposure to potentially traumatic
events [27]. These findings were consistent with
most of the studies conducted in the area [4,28].
Our study showed that exposure to war
traumatic events lead to post traumatic stress
disorder in which 36% of children showed full
criteria of PTSD. Such rate of PTSD was
consistent with previous studies in the area [4,28,
29,5]. Also, in study of 600 adolescents aged 12-
16 years from South Lebanon and Gaza Strip
showed that adolescents from Gaza Strip and
South Lebanon have been exposed to various
types of trauma during war, namely having family
members killed, injured and houses demolished.
Prevalence of PTSD in Palestinian and
Lebanese adolescents was 25.7% [30].
Regarding gender, females reported more
traumatic events than boys. This gender
differences had been reported in previous
studies involving adolescent and adult population
[31,32]. Our rate of PTSD is consistent with study
of 920 children and adolescents from refugee
minor’s population 12 to 18 years old in 2002 in
the Netherlands, 40% met criteria for PTSD at
time one, and 16% endorsed late-onset PTSD
[33]. Similarly data collected from a sample of
139 adolescents 12 to 17 years old in Gaza Strip
showed that rate of posttraumatic stress disorder
(PTSD) was 56.8%. Significant risk factors for
PTSD were exposure, female gender, older age,
and an unemployed father living in city and
village had more PTSD than children live in
camps, avoidance was more in children living in
city and intrusion was more in children living in
village [34]. These findings could be explained by
exposure of children living in cities to heavy
bombardment and shelling than villages and
camps.
The results showed that 30.9% of Palestinian
children reported anxiety disorder and no
differences between boys and girls in anxiety
disorder. This results is consistent with previous
study in the area in study with 409 children and
young people aged 9-18 years in the Gaza Strip
during continuing exposure to political trauma
during the last incursion of the Gaza Strip on
summer of 2006 showed that 25.4% reported
anxiety disorder, girls had more anxiety than
boys [35]. Also in another study [4] in study of
200 families from North Gaza and East Gaza
who had exposed to continuous shelling in 2006,
the sample includes 197 children and 200
parents. The results showed that 33.9% of
children had anxiety disorder. Children living in
camps presented higher levels of anxiety than
children living in the city and villages, anxiety
was more in children coming from families with
family income less than $300 and whom father
and mother education was less than elementary
education. This is more than previously rates of
anxiety in the same area [36,37].
The study showed that Palestinian children were
proud of their citizenship; they feel safe when
they were with their caregivers, and their spiritual
beliefs were a source of strength for them, and
were proud of their ethnic background. The study
showed that the highest factor for resilience was
contextual components that facilitate a sense of
belonging. Being a girl was more protective in
which they were more resilience and had more
personal skills, peer component, and social skills,
spiritual beliefs, culture, and educational items.
Total resilience scores and subscale contextual
components were more in children living in
camps and villages than in cities, individual factor
was more in children living in camps than in cities
and relationship with caregiver were more in
children live in villages than in cities. Children
with family monthly income more than $301 had
more individual factor than children from families
of $300 and less. Our results were consistent
with study of 600 adolescents aged 12-16 years
from South Lebanon and Gaza Strip which found
that adolescents from Gaza who were under
economic pressure were at the highest risk
for psychological distress including PTSD,
depression and anxiety [30]. Economic pressure
has an impact on adolescents’ mental health
both directly as a source of stress and indirectly
through reducing resources that may buffer the
impact of traumatic events. The results showed
that having high traumatic events, more anxiety
symptoms, and high PSTD significantly
decreased total resilience in Palestinian children.
Our findings were consistent with previous
findings regarding the negative impact of loss on
children’s functioning [38] and the impact of
traumatic events on resilience [15]. Our results
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
11
consistent with study of 90 children and
adolescents and their families who participated in
an investigation assessing the impact of
residential fires in USA on children and their
families which indicated that loss and age
predicted resilience in children and adolescents.
Specifically, older children exhibited higher levels
of resilience as compared to younger children
and children who reported lower resource loss
also exhibited higher levels of resilience. Gender,
however, did not emerge as a predictor of
resilience [39].
5. CONCLUSION AND RECOMMENDA-
TIONS
The study showed that boys living in a city
reported severe traumatic events, decrease their
resilience, and affect negatively their relationship
with peers and parents and increase
psychological problems such as PTSD and
anxiety. Due to political complexity, psyhocosical
programs targeting children in safe places
including both boys and girls and their parents
much continue for longer period to overcome the
long-standing effect of trauma on children
psychological wellbeing. Such programs could be
carried out by local NOGs and CBOs working in
civil society and funding of such programs from
international community. Our findings again
highlighted the need to create new programs
teaching children ways of coping and overcoming
stressors and being more resilient. Such
programs could include non-curriculum activities,
using theater and music, role play, creative
activities, folklore dancing, and handcraft for
girls. Local NGOs, CBOs, schools, sport clubs,
and other community places funded by
international donors could carry out such
activities.
This study had opened ideas for new era of
research which may include impact of other
important factors beside trauma such as stress
due to siege and blockade on children, and role
of poverty and community violence in increasing
children mental health problems. Also, further
study of types of coping strategies used by
children to overcome the impact of stress.
Moreover, other protective factors such as the
role of social and family support in helping
children dealing with stress and trauma. And
finally, impact of stress on children school
performance and relation with peers.
6. STUDY LIMITATIONS
There is limitation of the study in which only we
investigated the impact of trauma and not other
risk factors such as poverty, large family size,
community violence, parental influence, and
stressors due to siege and closure.
NOTE
We used for the entire format of our paper the
following style:
https://owl.english.purdue.edu/media/pdf/200902
12013008_560.pdf [40]
ACKNOWLEDGMENTS
We are appreciative of the children for their
cooperation during this study.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
REFERENCES
1. Ministry of Health. Report of Health Status
of Palestinians in the Gaza Strip.
Palestinian Authority. Gaza Strip; 2012.
Available:http:/www.moh.gov.ps
2. Thabet AA, Abed Y, Vostanis P.
Comorbidity of post-traumatic stress
disorder and depression among refugee
children during war conflict. Journal of
Child Psychology and Psychiatry. 2004;
45:533-542.
3. Thabet AA, Abdulla T, El Helou M,
Vostanis P. Effect of trauma on
children mental health in the Gaza Strip
and west bank chapter in a book (Eds)
Greenbaum, CW, Veerman, P, Bacon-
Shnoor, N Protection of children during
Armed political conflict A Multidisciplinary
Perspective. 2006;123-138.
4. Thabet A, Abu Tawahina A, El Sarraj
Eyad, Vostanis P. Exposure to war trauma
and PTSD among parents and children in
the Gaza Strip. European Child &
Adolescent Psychiatry. 2008;17:191-196.
5. Qouta S, Punamäki RL, Montgomery E,
El Sarraj E. Predictors of psychological
distress and positive resources among
Palestinian adolescents: Trauma, child,
and mothering characteristics. Child Abuse
& Neglect. 2007;31:699-717.
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
12
6. Espié E, Gaboulaud V, Baubet T, Casas
G, Mouchenik Y, Yun O, et al. Trauma
related psychological disorders among
Palestinian children and adults in Gaza
and West Bank. International Journal of
Mental Health Systems. 2009;3:21-25.
7. Dubow EF, Huesmann LR, Boxer P. A
social-cognitive-ecological framework for
understanding the impact of exposure to
persistent ethnic-political violence on
children’s psychosocial adjustment.
Clinical Child Family Psychology Review.
2009;12:113-126.
8. Elbert T, Schauer M, Schauer E, Huschka
B, Hirth M, Neuner F. Trauma-related
impairment in children-A survey in Sri
Lankan provinces affected by armed
conflict. Child Abuse & Neglect. 2009;33:
238-246.
9. Llabre MM, Hadi F. War-related exposure
and psychological distress as predictors of
health and sleep: A longitudinal study of
Kuwaiti children Psychosomatic Medicine.
2009;71:776-783.
10. Masten AS. Developmental psychopath-
logy: Pathways to the future. International
Journal of Behavioral Development.
2006;30(1):47–54.
DOI:10.1177/0165025406059974.
11. Hjemdal O, Martinussen M, Rosenvinge
JH. Preliminary results from the
development and validation of a
Norwegian scale for measuring adult
resilience. Journal of Norway Psychology
Association. 2001;38:310-317.
12. Chan I, Wong KN. Resilience is associated
with better recovery in Chinese people
diagnosed with coronary heart disease.
Psychology Health. 2006;21:335-349.
13. Haynes DF, Watt PJ. The lived experience
of healthy behaviors in people with
debilitating illness. Holistic Nursing
Practice. 2008;22:44-53.
14. Costanzo ES, Singer BH. Psychosocial
adjustment among cancer survivors:
Findings from a national survey of health
and well-being. Health Psychology. 2009;
28:147-156.
15. Bonanno GA. Loss, trauma, and human
resilience: Have we underestimated the
human capacity to thrive after extremely
aversive events? American Psychologist.
2004;59:20–28.
DOI:10.1037/0003-066X.59.1.20.
16. Hill HM, Madhere S. Exposure to
community violence and African-American
children: A multidimensional model of risks
and resources. Journal of Community
Psychology. 1996;24:26-43.
17. O’Donnell DA, Schwab-Stone ME, Muyeed
AZ. Multidimensional resilience in urban
children exposed to community violence.
Child Development. 2002;73:1265-1282.
18. Buka S, Stichick T, Birdthistle I, Earls FA.
Youth exposure to violence: Prevalence,
risks and consequences. American Journal
of Orthopsychiatry. 2001;7:298-310.
19. Plybon LE, Kliewer W. Neighborhood types
and externalizing behavior in urban school-
age children: Tests of direct, mediated,
and moderated effects. Journal of Child
and Family Studies. 2001;10: 419-437.
20. Garbarino J, Dubrow N, Kostelny K, Pardo
C. Children in danger. San Francisco:
Jossey-Bass; 1992.
21. Ozer EJ, Weinstein RS. Urban
adolescents’ exposure to community
violence: The role of support, school
safety, and social constraints in a school-
based sample of boys and girls. Journal of
Clinical Child and Adolescent Psychology.
2004;33:463-486.
22. Mowbray CT, Woolley ME, Grogan-Kaylor
A, Gant M, Gilster ME, Williams Shank TR.
Neighborhood research from a spatially
oriented strengths perspective. Journal of
Community Psychology. 2007:35;667-680.
23. Rodriguez N, Steinberg A, Pynoos RS.
UCLA PTSD Index for DSM-IV instrument
information: Child version, parent version,
adolescent version. Los Angeles, CA:
UCLA Trauma Psychiatry Services; 1999.
24. Reynolds CR, Richmond BO. What I think
and feel: A revised measure of children’s
manifest anxiety. Journal of Abnormal
Child Psychology.1978:25;15-22.
25. Reynolds CR. Concurrent validity of what I
think and feel: The Revised Children’s
Manifest Anxiety Scale. Journal of
Consulting and Clinical Psychology.
1980;48:774-775.
26. Lengua LJ, Sandler IN. Self-regulation as a
moderator of the relation between coping
and symptomatology in children of divorce.
Journal of Abnormal Child Psychology.
1996;24:681-670.
27. Tolin DF, Foa EB. Gender differences in
trauma and posttraumatic stress disorder:
A quantitative review of 25 years of
research. Psychological Bulletin. 2006;
132;959-992.
28. Thabet AA, Abu Nada I, Shivram R, Winter
EW, Vostanis P. Parenting support and
PTSD in children of a war zone.
Abdelaziz and Sanaa; BJESBS, 11(1): 1-13, 2015; Article no.BJESBS.19101
13
International Journal of Social Psychiatry.
2009;55:226-237.
29. Abdeen Z, Qaswari R, Nabil S, Shaheen
M. Psychological reactions to Israeli
occupation: Findings from the national
study of school-based screening in
Palestine. International Journal of
Behavioral Development. 2008;32:290-
297.
30. Khamis V. Impact of war, religiosity and
ideology on PTSD and psychiatric
disorders in adolescents from Gaza Strip
and South Lebanon. Social Science &
Medicine. 2012;74:2005-2011.
31. Acierno RK, Resnick H, Saunders B, De
Arellano M, Best C, Assault J. PTSD,
family substance use, and depression as
risk factors for cigarette use in youth:
findings from the National Survey of
Participants. Trauma Stress. 2000;13:381-
396.
32. Stein MB, Forde DR. Gender differences in
susceptibility to posttraumatic stress
disorder. Behaviour Research Therapy.
2000;38(6):619-628.
33. Geert ES, Gerty JL, Lensvelt-Mulders M,
Jeroen W, Knipscheer B, Gersons BR,
Rolf J, Kleber RJ. Late-Onset PTSD in
Unaccompanied Refugee Minors:
Exploring the Predictive Utility of
Depression and Anxiety Symptoms.
Journal of Clinical Child & Adolescent
Psychology. 2011;40(5):742-755.
34. Ingridsdatter I, Nielsen L, Kolltveit S,
Thabet, AA, Christian T, Johnsen, Jm
Dyregrov A, Ståle Pallesen S, Laberg JC
Risk Factors for PTSD, Anxiety, and
Depression Among Adolescents in Gaza
Journal of Traumatic Stress. 2012;25:164-
170.
35. Thabet A, Abu Tawahina A, El Sarraj
Eyad, Vostanis P. Children Exposed to
Political Conflict: Implications for Health
Policy. Harvard Health Policy Review.
2007;8(2):47-57.
36. Thabet AA, Vostanis P. Social adversities
and anxiety disorders in the Gaza Strip.
Archives of Childhood Diseases. 1998;78:
439-442.
37. Thabet AA, Tawahina AA, Punamäki RL,
Vostanis P. Prevalence and Mental Health
Function of Resilience in Condition of
Military Siege and Violence in a
Palestinian Community Sample. J
Psychiatry. 2015; 18:274.
DOI:10.4172/Psychiatry.1000274.
38. Jones RT, Ribbe DP, Cunningham PB,
Weddle JD, Langley AK. Psychological
impact of fire disaster on children and their
parents. Behavior Modification. 2002;
26(2):163–186.
DOI:10.1177/0145445502026002003.
39. Goel KS, Amatya K, Jones RT, Ollendick
T. Child and adolescent resiliency following
a residential fire: The role of social support
and ethnicity. Journal of Child and Family
Studies. 2014;23:537–547.
Available:https://owl.english.purdue.edu/m
edia/pdf/20090212013008_560.pdf
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