Symptoms of PTSD among Children Living in War Zones in Same Cultural Context and Different Situations

Abstract

Situations of war and military conflict have been linked to the development of Post-Traumatic Stress Disorder (PTSD). To our knowledge, there are no studies that have examined, within the same conflict and the same culture, exposure to different traumatic events or traumatic events of different intensity. The aim of this study was to evaluate the symptoms of PTSD among Palestinian schoolchildren in two different areas of Hebron. A total of 381 schoolchildren from different parts of Hebron participated in the study. To evaluate the symptoms of PTSD, the children were asked to complete the Child Post Traumatic Stress Reaction Index. To evaluate the traumatic events experienced, they completed the Gaza Traumatic Event Checklist. Results indicate that 77.4% of the children living in Hebron show symptoms of moderate-to-severe PTSD, and 20.5% of them meet the DSM-IV diagnostic criteria for chronic PTSD. There were no significant differences in total symptoms between the two areas of Hebron, but there were differences within the specific types of symptoms. It is clear that the traumatic events of the war lead to the development of post-traumatic stress in children and that psychological intervention is necessary.

Full text

47
Journal of Muslim Mental Health
ISSN1556-4908
Volume 7, Issue 2, 2013
http://hdl.handle.net/2027/spo.10381607.0007.203
Symptoms of PTSD among Children Living
in War Zones in Same Cultural Context and
Different Situations
Ahmed F. Fasfous, Isabel Peralta- Ramírez,
and Miguel Pérez- García
School of Psychology - University of Granada (Spain)
Centro de Investigación Mente, Cerebro y Comportamiento (CIMCYC).
University of Granada (UGR). Spain.
Abstract
Situations of war and military conflict have been linked to the development of
Post- Traumatic Stress Disorder (PTSD). To our knowledge, there are no studies that
have examined, within the same conflict and the same culture, exposure to dif-
ferent traumatic events or traumatic events of different intensity. The aim of this
study was to evaluate the symptoms of PTSD among Palestinian schoolchildren in
two different areas of Hebron. A total of 381 schoolchildren from different parts of
Hebron participated in the study. To evaluate the symptoms of PTSD, the children
were asked to complete the Child Post Traumatic Stress Reaction Index. To evalu-
ate the traumatic events experienced, they completed the Gaza Traumatic Event
Checklist. Results indicate that 77.4% of the children living in Hebron show symp-
toms of moderate- to- severe PTSD, and 20.5% of them meet the DSM- IV diagnostic
criteria for chronic PTSD. There were no significant differences in total symptoms
between the two areas of Hebron, but there were differences within the specific
types of symptoms. It is clear that the traumatic events of the war lead to the de-
velopment of post- traumatic stress in children and that psychological intervention
is necessary.
Literature suggests that exposure to the traumatic events of war is related to
high levels of PTSD among the victims of military conicts. However, there are
important dierences between the stressors and prevalence of PTSD in each
conict due to cultural dierences, type of conict, and PTSD instruments ad-

48 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
ministrated. erefore, this study will compare Palestinian children from the
same city, subjugated to the same conict, and raised in the same culture; how-
ever the sample draws from two dierent types of stressful contexts.
In this regard, studies conducted in war zones indicate that exposure to
the traumatic event leads to the development of PTSD in childhood and adult-
hood (Attari, Dashty, & Mahmoodi, 2006; Elbert et al., 2009; Carlson & Rosser-
Hogan, 1994; Nader, Pynoos, Fairbanks, Al- Ajeel, & Al- Asfour, 1993; Qouta,
Punamaki, & El Sarraj, 2003; abet & Vostanis, 2000). Dierent studies have
been performed to determine the incidence of PTSD resulting from exposure
to traumatic events. Studies from dierent conicts have produced results that
range from a high incidence to low incidence of children with PTSD who had
been exposed to war and conicts. A study carried out on Kuwaiti children
who had lived through the Gulf war found that 70% of children showed symp-
toms of PTSD ranging from moderate to severe (Nader et al., 1993). A later
study involving a sample of Iranian children who had witnessed a public hang-
ing next to their school in Isfahan found that 75% reported a tendency for
moderate- to- severe symptoms of PTSD (Attari et al., 2006).
In one study conducted in Palestine, 41% of the children of Gaza revealed
a tendency to show moderate- to- severe PTSD symptoms (abet & Vostanis,
2000). A dierent study showed that the incidence of post- traumatic stress
in 121 Palestinian children exposed to bombings was twice as high as results
found in the previous study; 87% exhibited moderate to severe PTSD (Qouta
et al., 2003). All of these studies found a high incidence of PTSD in children
exposed to situations of war and conict. However, other studies have found
lower incidence rates. For example, a study conducted in Lebanon found that
only 20% of Lebanese children who had been exposed to bombings and ter-
rorist attacks met the diagnostic criteria for PTSD (Saigh, 1991). In addition, a
study conducted in Sri Lanka following two decades of war and unrest found
that 25% of the country’s children met the diagnostic criteria for PTSD.
With regard to gender dierences in the development of PTSD aer living
through situations of conict or war, most studies nd that girls show more
symptoms of the disorder than boys (Durakovic- Belko, Kulenovic, & Dapic,
2003; Macksoud & Aber, 1996; Miller El- Masri, Allodi, & Qouta, 1999). How-
ever, Khamis (2005) conducted a study in Palestine and found that boys dis-
played more PTSD symptoms than girls. Contrary to both, a study performed
in Palestine by Elbedour, Onwuegbuzie, Ghannamc, Whitcome, and Abu Hein
(2007) found no signicant dierences between the two sexes.
ese studies, however, did not give consideration to important variables
that could explain their diering ndings. For example, some studies evalu-
ated PTSD aer the conict had ended (Awadah, Vance, El- Beblawi, & Pumar-
iega, 1998), or they compared very dierent conicts (De Jong et al., 2001). For
these reasons, we decided to study PTSD in children who are subject to stress

PTSD Among Children Living in War Zones 49
situations of the same conict and in the same cultural and socio- demographic
context.
e conict in Palestine is still underway. For over six decades, the Pales-
tinian population has lived through dierent types of traumatic events (e.g.,
killings, arrests, and destruction of homes and agricultural land). e city of
Hebron is recognized in Palestine for its atypical circumstances: it is the larg-
est city in the West Bank (a Palestinian territory) and a group of Israeli settlers
currently live in the historic center of the city (Palestinian Central Bureau of
Statistics, 2009). Aer the signing of the 1997 Hebron Agreement by the Israeli
government and the Palestinian National Authority, the city was divided into
two areas. e area called H1 (80% of the city) is under Palestinian control and
is inhabited by over 115,000 Palestinians. e area called H2 has a population
of over 35,000 Palestinians and about 500 Israeli settlers. is part of the city,
according to the Hebron Agreement, is to be under Israeli military control,
although its administration is the responsibility of the Palestinian authority.
During the Second Intifada (2000) the Israeli army took control of H1 for sev-
eral months (B’tselem, 2003). At the time of this study, H1 was under Palestin-
ian control, although the Israeli army made incursions into the area.
Children, as part of the Palestinian population of Hebron, are an especially
vulnerable group. ey experience a variety of violent attacks in their daily
lives. It is therefore necessary that studies be conducted to illustrate the trau-
mas that boys and girls living in the city may experience, as well as the post-
traumatic symptoms they may display as a result. us far, few studies have fo-
cused on PTSD among the Palestinian children of this region. One of the most
important studies focused on Palestinian schoolchildren of the West Bank and
found that 34.1% of them suered from PTSD. Most of these children were
older, employed male refugees (Khamis, 2005). Other studies revealed high
rates of PTSD in primary school- aged children who had experienced the war
rsthand. Of the sample, 39% showed symptoms ranging from moderate to
severe (abet & Vostanis, 1999).
To our knowledge, no previous studies have considered dierences in type
of stressor or symptoms in dierent Palestinian territories. e aim of this
study is to evaluate the impact of dierent traumatic events and the psycho-
logical consequences of their aermath for children living in conict zones,
such as Hebron. It is important to note that this study allows variables such as
culture and type of conict to be controlled, as it compares two situations of
exposure to traumatic events (H1 and H2) in the same city and with the same
population. Also, as secondary objectives, (1) the prevalence of the PTSD will
be studied, (2) if dierences between girls and boys in the type of stressors
and symptoms exist, and, nally, (3) if a positive relation between the number
of stressors and symptoms exist. We hypothesized that type of stressor and
symptoms will be dierent for H1 and H2, that the prevalence of PTSD will

50 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
be similar to previously reported, that girls will experience more PTSD symp-
toms and, nally, that the more traumatic events children experience, the more
symptoms children suer.
Methods
Target Population
According to the Ministry of Education in the city of Hebron, there are 4,241
13- year- olds attending 59 schools. In H1, under Palestinian authority, there
are 34 schools (16 for boys and 18 for girls) which have 2,732 (1,463 boys and
1,269 girls) 7th grade students. In H1, under Israeli control (with the presence
of some Israeli settlers in addition to the Palestinian population), there are 25
schools (12 for boys and 13 for girls) which have 1,509 (671 boys and 838 girls)
7th grade students.
Participants
A total of 381 thirteen- year- old students (190 boys and 191 girls) participated
in this study. is sample was divided into two groups, depending on where
the students live in the city. e rst group has 232 students (121 boys and
111 girls) who attend four schools located in H1. e second group has 149
students (69 boys and 80 girls) who attend ve schools located in H2. In this
study, the two dierent groups are equal in father’s employment status (10%
of the children’s fathers (n=15) in H2 area were unemployed, while in H1 area
7% of children’s fathers (n=16) were unemployed). is data was collected in a
questionnaire that included questions about socioeconomic status.
Measures
Child Post Traumatic Stress Reaction Index (CPTSD- RI:
Frederick, 1985):
e CPTSD- RI is a 20- item self- report questionnaire designed to assess PTSD
reactions following exposure to a wide range of events in children and ado-
lescents, ages 6 to 16 years old. e index includes three subscales: intrusion
(seven items), avoidance (ve items), and arousal (ve items), along with three
additional items (abet, Abed, & Vostanis, 2002).
e responses are presented in a Likert- type 5- point rating scale (0- 4).
Based upon score ranges, the questionnaire classies the degree of reaction
as follows: scores of 0- 11 = doubtful; 12- 24 = mild; 25- 39 = moderate; 40- 59
= severe; and above 60 = very severe (Frederick, 1985). Some previous studies

PTSD Among Children Living in War Zones 51
suggest that a score of 40 or more is closely related to the diagnosis of Post-
Traumatic Stress (Pynoos et al., 1993). e inter- rater reliability of this instru-
ment is high and its Cohen’s kappa is 0.87 (Pynoos et al., 1987). is instru-
ment has also shown high test- retest reliability (Goenjian et al., 1995). e
CPTSD- RI has been translated to Arabic and validated for this culture (abet
& Vostanis, 1999).
Gaza Traumatic Event Checklist (Abu Hein, Qouta, abet, &
El Sarraj, 1993):
is checklist of items covers dierent types of traumatic events that a child
may have experienced during his or her lifetime. e version used for this
study is a subsequent 20- item version that describes the most common trau-
matic experiences in the Gaza strip. e scale has been validated and deemed
reliable for the Palestinian population (abet, Abed, & Vostanis, 2004). is
instrument uses a dichotomous response format (abet & Vostanis, 1999).
Procedure
Aer the research project was planned, we requested permission from the Pal-
estinian Ministry of Education to conduct the study. e Ministry provided
information regarding the number of schools and their geographical distribu-
tion. e next step was to select the sample randomly, using the SPSS program.
en we went to the schools where the random sample of students attended to
obtain the directors’ permission to begin assessing the participants.
In most cases, the tests were administered early in the morning and in
classrooms with teachers who facilitated the activity. All of the subjects par-
ticipated in the study on a voluntary basis. Classroom presentations about ob-
jectives and process of this study were given to children by researcher. en
they invite children to participate in this study. However, children were chosen
randomly using the SPSS program.
Variables and statistical analyses
Variables
e independent variables are gender (male and female) and place (H1 and
H2), both with two levels.
To study the relationship between the number of stressful events and the
number of symptoms, a quartile variable was generated for traumatic events,
with four levels: Q1 (1- 2), Q2 (3- 4), Q3 (5- 6- 7), Q4 (8- 20).
e dependent variables were the scores obtained in the dierent rating
scales administered. e total score of traumatic events included in the Gaza

52 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
Traumatic Event Checklist equals the sum of the scoring for each event, which
was coded “1” if the event occurred and “0” if it did not occur. e total score
of symptoms included in the CPTSD- RI equals the sum of the scoring for each
item, which was coded “0” for “never” and up to “4” for “always”.
Statistical analyses
Analysis has been described according to each objective and following the
same order. Also, as indicated before, objectives have been more claried and
ordered. In the results section, titles have been changed to be closer related
with the objectives description and the order to show them has been matched
to objectives. All results were processed in an SPSS database (version 15.0). To
address the objective of studying dierences in stressors and symptoms in two
dierent contexts (H1 vs. H2; objective 1), a Student’s t- test was used. To know
what stressors and symptoms are associated with H1 or H2, an analysis of con-
tingency tables was performed. In the case of the symptoms questionnaire, the
responses to each item were classied into three categories, to avoid infrequent
responses: Never = Never; Sometimes and Not Very Oen = Sometimes; Al-
most Always and Always = Almost Always.
To know the prevalence of PTSD in the sample (objective 2), number of
children scoring more than 40 in the CPTSD- RI were obtained.
Also, to determine if there were dierences between girls and boys in the
two areas of Hebron (objective 3), both in terms of the total number of trau-
matic events and in total number of symptoms, four t- tests were performed,
with the independent variables “gender in H1” (boys in H1 vs. girls in H1),
“gender in H2” (boys in H2 vs. girls in H2), “boys in both areas” (boys in H1 vs.
boys in H2) and “girls in both areas” (girls in H1 vs. girls in H2). To know what
stressors and symptoms are associated with gender, an analysis of contingency
tables was performed.
We decided to do a quartile approach of number of stressors to obtain two
things: to provide clinical information about what symptoms could you expect
in children who suer certain numbers of stressors and, 2) to not categorize the
number of stressors in a subjective way. We add this rationality in the paper.
Finally, to study the relationship between traumatic events and symptoms
and provide more clinical information about what symptoms you could expect
in children who suer a certain number of stressors, we obtained four groups
from the total of traumatic events variable using the quartile score in order to
avoid a subjective categorization of the variable.
Dierences between those four groups in total of symptom variable were
studied using an ANOVA. Due to the number of statistical analysis performed,
the signicant level was set at 0.01 to reduce the likelihood of type I error.

PTSD Among Children Living in War Zones 53
Results
As a result of not completing the two main tests of this study, data for 8 chil-
dren were missing in the Gaza traumatic events, while data for other 14 chil-
dren were missing in the CPTSD- IR. In our study the mean number of trau-
matic events experienced by children in Hebron is 6.03. e intensity of these
traumatic events occurred varies: 9.4% of the children have seen their homes
destroyed and 94.8% of the children have seen images of dead and injured peo-
ple on television.
A descriptive analysis was conducted to study how many participants
showed symptoms of PTSD, in accordance with the cut- o points proposed
by the author. Of the total, 1.8% (n=7) showed no symptoms, 16.5 % (n=63)
displayed mild PTSD, 47% (n= 179) displayed moderate PTSD, 30.4% (n= 116)
displayed severe PTSD and 0.5% (n= 2) suered from very severe PTSD. e
mean total of symptoms shown was 34.18 (DT= 11.24). According to the three
scales of the CPTSD- RI, 20.5% of the sample meets the DSM- IV diagnostic
criteria for PTSD (APA, 1994).
Gender
First, we studied the dierences between boys and girls in the amount and type
of traumatic events. We found statistically signicant dierences between boys
and girls [t (1,360) = 5.286; p < 0.000], with the boys’ total (M= 7.10; SD=4.22)
being higher than the girls’ total of traumatic events (M=. 4.96; SD: 3.57).
Also, we found dierences in the type of traumatic event experienced by
children using a cross- tab analysis (gender x items). e results indicate that
there are seven items of traumatic events that boys have suered most fre-
quently. e most important ones are: seeing a friend get hit by a bullet (item
7) [χ2 = 27.0; p < 0.000]; being hit (item 8) [χ2 = 22.3; p < 0.000]; seeing friend
be arrested by soldiers (item 13) [χ2 = 14.3; p < 0.000]; or seeing soldiers burst
into your home at night (item 12) [χ2 = 13; p < 0.000] (see Table 1).
With regard to the symptoms of PTSD, no signicant dierences in the
total were found, but it is more frequent for the girls to relive the images repeat-
edly (almost always > 42.9%) [χ2 = 13.8; p < 0.001], and to be upset by remind-
ers (almost always > 52.4%) [χ2 =12.0; p < 0.002].
Place (H1 vs. H2)
Considering the place variable, no signicant dierences were found between
the two areas in the total of traumatic events. ere were dierences, however,
within the type of traumatic event experienced. e results show that it is more
frequent for the people of H1 to nd about the death of a friend at the hands

54 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
of the Israeli army (item 3) and to witness the attack of nearby houses with
bombs, artillery, or heavy weaponry (item 16) than for the people of H2. On
the other hand, it is more frequent for the people of H2 to have to wait for many
hours at checkpoints (item 4), to see friends being hit (item 8) or arrested (item
13), to be hit themselves (item 10), and to see soldiers break into their homes
during the day (item 11) or at night (item 12; see Table 2).
While there were no signicant dierences between the two areas in the
total of symptoms, there were signicant results within the types of symptoms.
Children of H2 showed more frequency in being easily startled (almost always
> 36.9) [χ2 = 17.4; p < 0.000], and to have a higher likelihood of memory prob-
lems (almost always > 40.9) [χ2 = 11.19; p < 0.004]. On the other hand, the
TABLE 1. The percentage of occurrence and χ2 of each traumatic event by gender.
Boys Girls
THE TRAUMATIC EVENT % Yes % Yes % Yes χ2 P
1. Seeing images of dead and injured people on TV 94.8 94.7 94.8 0.00 0.990
2. Seeing aerial bombings against houses and streets 80.3 86.3 74.7 8.12 0.004
3. Finding out about the death of a friend at the hands
of the Israeli army 24.1 29.6 18.9 5.88 0.015
4. Waiting for many hours at the checkpoints 47.0 52.1 42.3 3.63 0.057
5. Finding out that a father, a sibling, or other close
family member has been killed by the
occupying forces 29.1 31.7 26.7 1.17 0.280
6. Witnessing the destruction of a friend’s home 22.8 27.9 17.9 5.38 0.020
7. Seeing a friend get hit by a bullet 23.9 35.3 12.6 27.0 0.000
8. Seeing a friend being hit by soldiers 37.8 47.9 27.7 16.4 0.000
9. Seeing a father, a sibling, or other family member
killed by soldiers 11.8 15.3 8.4 4.26 0.039
10. Being hit or humiliated by soldiers 31.0 42.3 19.9 22.3 0.000
11. Seeing soldiers break into your home during
the day 28.9 31.7 26.2 1.43 0.231
12. Seeing soldiers break into your home at night 32.5 41.5 24.1 13.0 0.000
13. Seeing a friend arrested by soldiers 31.5 40.5 22.5 14.3 0.000
14. Seeing a parent or a sibling get hit by a bullet 12.6 15.3 9.9 2.44 0.118
15. Seeing your home being bombed by artillery and
heavy weaponry 14.7 18.9 10.5 5.46 0.019
16. Witnessing the attack of nearby homes by bombs,
artillery, or heavy weaponry 25.7 31.6 20.0 6.66 0.010
17. Seeing a parent or a sibling being arrested
by soldiers 18.1 22.1 14.2 3.98 0.046
18. Seeing a parent or a sibling being hit by soldiers 17.8 21.1 14.7 2.66 0.103
19. Being injured by a (rubber) bullet 10.0 11.1 8.9 0.47 0.494
20. Witnessing the destruction of your home 9.4 13.2 5.8 6.09 0.014
*The mean is not included because it is the same as the percentage of Yes responses

PTSD Among Children Living in War Zones 55
people of H1 demonstrated a stronger sense of foreshadowing (almost always
> 29.8) [χ2 = 9.32; p < 0.009].
Relationship between traumatic events and symptoms
It was found that the number of traumatic events is related to the number of
PTSD symptoms displayed. e results demonstrated that people who have ex-
perienced more traumatic events display more post- traumatic stress symptoms
(F (3,357) = 11.53; p < 0.000). (See gure 1). Back analyses showed that there
were statistically signicant dierences in the post- traumatic stress symptoms
displayed by boys of quartile 1, 2, and 3, and between quartile 2 and 4. is data
appeared with a clear linear tendency (F (1,357) = 34.41; p < 0.000).
TABLE 2. The percentage of occurrence and χ2 of each traumatic event by area.
H1 H2
THE TRAUMATIC EVENT % Yes % Yes % Yes χ2 P
1. Seeing images of dead and injured people on TV 94.8 93.5 96.6 1.76 0.184
2. Seeing aerial bombings against houses and streets 80.3 83.5 75.8 3.43 0.064
3. Finding out about the death of a friend at the hands
of the Israeli army 24.1 30.9 14.1 13.84 0.000
4. Waiting for many hours at the checkpoints 47.0 41.3 56.4 8.24 0.004
5. Finding out that a father, a sibling, or other close
family member has been killed by the
occupying forces 29.1 30.7 26.8 0.66 0.416
6. Witnessing the destruction of a friend’s home 22.8 21.2 25.5 0.95 0.331
7. Seeing a friend get hit by a bullet 23.9 22.4 26.2 0.71 0.401
8. Seeing a friend being hit by soldiers 37.8 26.7 55.0 30.9 0.000
9. Seeing a father, a sibling, or other family member
killed by soldiers 11.8 13.4 9.4 1.41 0.236
10. Being hit or humiliated by soldiers 31.0 24.7 40.9 11.2 0.001
11. Seeing soldiers break into your home during the day 28.9 22.5 38.9 11.9 0.001
12. Seeing soldiers break into your home at night 32.5 26.8 41.9 9.28 0.002
13. Seeing a friend arrested by soldiers 31.5 25.9 40.3 8.73 0.003
14. Seeing a parent or a sibling get hit by a bullet 12.6 14.2 10.1 1.42 0.233
15. See your home being bombed by artillery or
heavy weaponry 14.7 14.2 15.4 0.11 0.744
16. Witnessing the attack of nearby homes by bombs,
artillery, or heavy weaponry 25.7 29.4 20.1 4.10 0.043
17. Seeing a parent or a sibling being arrested
by soldiers 18.1 19.0 16.8 0.31 0.575
18. Seeing a parent or a sibling being hit by soldiers 17.8 16.4 20.1 0.87 0.350
19. Being injured by a (rubber) bullet 10.0 10.8 8.7 0.44 0.506
20. Witnessing the destruction of your home 9.4 10.3 8.1 0.56 0.456
Note: H1 = area 1 of Hebron; H2 = area 2 of Hebron.
*The mean is not included because it is the same as the percentage of Yes responses

56 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
Discussion
e aim of this study was to compare two groups of Palestinian children, sub-
jected to the same situation of decades- long conict and who belong to the
same cultural and socioeconomic context. Another goal was to compare these
two groups based on dierent stressor contexts, areas H1 and H2 of Hebron.
e ndings reveal that the mean number of traumatic events experienced by
the children of Hebron is 6.03. In addition, 77.4% of the children living in the
city of Hebron who participated in this study showed symptoms of moderate
or severe PTSD, and 20.5% of them meet the DSM- IV diagnostic criteria for
PTSD (APA, 1994). Results also showed dierent types of PTSD stressors and
symptoms depending on the area of Hebron where the children were living, and
a positive direct relationship between the number of stressors and symptoms.
More specically, no signicant dierences were found in the mean num-
Figure 1. Relationship between the mean number of symptoms and the
number of traumatic events.

PTSD Among Children Living in War Zones 57
ber of traumatic events experienced by the people living in the two areas (H1
and H2). However, the type of traumatic events experienced did, in fact, dier.
We found that events in H1 were more related to dangerous acts and death
while events in H2 were more related to daily life. is may be due to the fact
that the Second Intifada involved young Palestinians living in H1 and Israeli
soldiers at the border of H2. Moreover, more infrastructures were bombed by
Israeli troops in H1 during this Intifada. It is also important to note that the
people of H2 must oen wait for many hours at checkpoints because they are
so plentiful in this area: two of the four schools included in the study (the Al-
Ibrahimeyah Primary School for boys, and the Córdoba Primary School for
girls) have electronic checkpoints on both sides of the building, and the other
two (the Al- Hajereyeh Primary School for girls, and the Jawhar Primary School
for boys) have regular checkpoints. Also, dierences in the type of symptoms
between H1 and H2 were found. Children under Israeli control experience
more concrete and physiological symptoms such as being easily startled or
memory problems. is could be explained because H2 children are exposed
to more chronic stressors (such as crossing checkpoints several times a day).
Chronic events have been shown to cause memory problems due to neural
injury in the hippocampus (Astur et al., 2006)
Examining the development of PTSD by area, we found that H1 girls
display more post- traumatic stress than H1 boys. In H2, however, girls did
not experience more PTSD than boys. e results of H2 concur with studies
carried out previously (Elbedour et al., 2007; Saigh, 1991; abet & Vostanis,
1999). is could be explained by the typology of the traumatic events, since
we nd that when the events are chronic and frequent, no dierences are de-
tected between boys and girls. Specically, in the case of H2, the stressors oc-
cur frequently (almost daily) and there are no discernible gender dierences.
In H1, on the other hand, the traumatic events are not as frequent and gender
dierences are more noticeable. ese results could perhaps also be explained
by the fact that at the time of the study, no Israeli military incursions into H1
had occurred, although the military remained present in H2.
It is likely that one of the factors contributing to dierences in percentages
in the development of post- traumatic stress is the duration of the stressor, since
in stressful situations that continue over a long period of time, as in Pales-
tine, studies tend to show high percentages of post- traumatic stress (Buydens-
Branchey, Noumair, & Branchey, 1990; Kang, Natelson, Mahan, Lee, & Murphy,
2003). However, in situations in which the stressful events are shorter- lived, the
percentages fall. Another factor that must be taken into account is when the
study took place, whether during a war or aerwards (Allwood, Bell- Dolan, &
Husain, 2002)
Studies that have looked into stressful events in conict- ridden popula-
tions have continuously found varying percentages for the development of

58 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
post- traumatic stress. In our case, the percentage is 77%, one of the highest
percentages. It coincides with the study by abet, Abed, and Vostanis (2004)
involving Palestinian refugee children, and the study by Attari and colleagues
(2006) involving Iranian children who had witnessed a public hanging. Other
studies, however, have found lower percentages (Elbedour et al., 2007; Khamis,
2005; Saigh, 1991; Nader et al., 1993; Smith, Perrin, Yule, Hacam, & Stuvland,
2002; abet & Vostanis, 2000). It is likely that one of the factors contribut-
ing to dierences in percentages in the development of post- traumatic stress
is the duration of the stressor. Studies tend to show high percentages of post-
traumatic stress in stressful situations that continue over a long period of time,
as in Palestine. However, in situations where the stressful events are short- lived,
the percentages tend to fall. Another factor that must be taken into account is
when the study took place (e.g. during or aer the war).
Among the most interesting results of this study is the nding that boys
suer more traumatic events than girls, which is similar to the ndings of many
previous studies (Husain et al., 1998; Khamis, 2005; Kuterovac, Dyregrov, &
Stuvland, 1994; abet & Vostanis, 1999; abet, Abu Tawahina, El Sarraj, &
Vostanis, 2008). However, it contrasts with another study that found that boys
and girls in Palestine experience the same number of traumatic events (Miller
et al., 1999). In our study, girls do not experience traumatic events in greater
proportion than boys, and they are equal to boys only in the situation of “see-
ing images of dead and injured people on TV”. is dierence between boys
and girls in the number of experienced traumatic events could be a result of the
socio- cultural factors. For example, girls in Hebron normally stay and play at
home more than boys, who spend a portion of their time outside their home.
Other reasons could be political; soldiers that are responsible for these events
may focus their aggression towards boys more than girls. In fact, Children at
this specic stage (13 years old) are entering the adolescence, and boys may be
more likely than girls to participate in risky behavior, putting them at a higher
risk of experiencing traumatic events.
In general terms, while the boys of our study experienced more traumatic
events, it was the girls who exhibited more frequently to relive the images and
to be upset by reminders. ese ndings coincide with other studies (Breslau,
Davis, Andreski, & Peterson, 1991; Kessler, 2000; Macksoud & Aber, 1996;
Qouta et al., 2003; Smith et al., 2002). Some studies, however, do not agree
with this statement, nding instead that men display more symptoms of PTSD
in conict situations (Khamis, 2005). Gender dierences in developing PTSD
symptoms could be due to how males and females percept and interpret trau-
matic events. Girls may internalize the same traumatic event more deeply than
boys, so their fear and reactions to such events might occur at a higher rate
(Greenberg & Schneider, 1995; Holbrook, Hoyt, Stein, & Sieber, 2002). An-

PTSD Among Children Living in War Zones 59
other reason could be the dierence in cognitive processes between boys and
girls (Simmons & Granvold, 2005).
Our study has certain limitations. e uniform 13- year- old age of the
sample limits the generalizability of our research. Given our results, it would
perhaps have been interesting to take into consideration other psychological
consequences of living through traumatic events, such as depression and be-
havior problems. Along these lines, it would have been interesting to examine
the cognitive consequences and academic impact of PTSD symptoms. is
topic should be addressed in future studies.
In short, it is clear that war and political violence has an eect on children
at the psychological level. Our study has shown that boys and girls in H1 and
H2 dier from each other in the type of stressors they experience and that both
show a high rate of post- traumatic stress symptoms.
References
Abu Hein, F., Qouta, S., abet, A. A., & El Sarraj, E. (1993). Trauma and mental
health of children in Gaza. British Medical Journal, 306, 1130- 1131. http://dx.doi.
org/10.1136/bmj.306.6885.1130- c
Allwood, M. A., Bell- Dolan, D., & Husain, S. A. (2002). Children’s trauma and ad-
justment reactions to violent and nonviolent war experiences. Journal of the
American Academy of Child and Adolescent Psychiatry, 41, 450- 457. http://dx.doi.
org/10.1097/00004583- 200204000- 00018
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental
disorders, DSM- IV, (4th ed., pp. 427- 429). Washington DC, American Psychiatric
Association.
Astur, R. S., St. Germain, S. A., Tolin, D., Ford, J., Russell, D., Stevens, M. (2006). Hip-
pocampus function predicts severity of post- traumatic stress disorder. Cyberpsy-
chology & Behavior, 9, 234- 240. http://dx.doi.org/10.1089/cpb.2006.9.234
Attari, A., Dashty, S., & Mahmoodi, M. (2006). Post- traumatic stress disorder in chil-
dren witnessing a public hanging in the Islamic Republic of Iran. Eastern Mediter-
ranean Health Journal, 12, 72- 80.
Awadh, A. M., Vance, B., El- Beblawi, V., & Pumariega, A. J. (1998). Eects of trauma of
the Gulf War on Kuwaiti children. Journal of Child and Family Studies 7, 493- 498.
http://dx.doi.org/10.1023/A:1022962127860
B’tselem, the Israeli Information Centre for Human Rights in the Occupied Territories.
(Status Report August 2003). Hebron, Area H- 2: Settlements Cause Mass Departure
of Palestinians. Jerusalem.
Breslau, N., Davis, G. C., Andreski, P., & Peterson, E. (1991). Traumatic events and post-
traumatic stress disorder in an urban population of young adults. Archives of General
Psychiatry, 48, 218- 222. http://dx.doi.org/10.1001/archpsyc.1991.01810270028003
Buydens- Branchey, L., Noumair, D., Branchey, M. (1990). Duration and intensity of
combat exposure and posttraumatic stress disorder in Vietnam veterans. Journal
of Nervous and Mental Disease, 178, 582- 587. http://dx.doi.org/10.1097/00005053-
199009000- 00005

60 Ahmed F. Fasfous, Isabel Peralta-Ramírez, and Miguel Pérez-García
Carlson, E. B., & Rosser- Hogan, R. (1994). Cross- cultural response to trauma: A study
of traumatic experiences and posttraumatic symptoms in Cambodian refugees.
Journal of Traumatic Stress, 7, 43- 58. http://dx.doi.org/10.1002/jts.2490070106
De Jong, J. T. V. M., Komproe, I. H., Van Ommeren, M., El Masri, M., Araya, M.,
Khaled, N., et al. (2001).?Lifetime events and posttraumatic stress disorder in 4
post conict settings. Journal of the American Medical Association, 286, 555- 562.
http://dx.doi.org/10.1001/jama.286.5.555
Durakovic- Belko, E., Kulenovic, A., & Dapic, R. (2003). Determinants of posttraumatic
adjustment in adolescents from Sarajevo who experienced war. Journal of Clinical
Psychology, 59, 27- 40. http://dx.doi.org/10.1002/jclp.10115
Elbedour, S., Onwuegbuzie, A. J., Ghannam, J., Whitcome, J., & Abu Hein, F. (2007).
Post- traumatic stress disorder, depression, and anxiety among Gaza Strip adoles-
cents in the wake of the second uprising (Intifada). Child Abuse & Neglect, 31,
719- 729. http://dx.doi.org/10.1016/j.chiabu.2005.09.006
Elbert, T., Schauer, M., Schauer, E., Huschka, B., Hirth, M., & Neuner, F. (2009). Trauma-
related impairment in children—A survey in Sri Lankan provinces aected by
armed conict. Child Abuse & Neglect, 33, 238- 246. http://dx.doi.org/10.1016/j.
chiabu.2008.02.008
Frederick, C. J. (1985). Selected foci in the spectrum of post- traumatic stress disorders.
In J. Laube & S. A. Murphy (Eds.), Perspectives on disaster recovery (pp. 110- 131).
East Norwalk, CT: Appleton- Century- Cros.
Goenjian, A. K., Pynoos, R. S., Steinberg, A. M., Najarian, L. M., Asarnow, J. R., Karay-
an, I., et al. (1995). Psychiatric comorbidity in children aer the 1988 earthquake
in Armenia. Journal of the American Academy of Child and Adolescent Psychiatry,
34, 1174- 1184. http://dx.doi.org/10.1097/00004583- 199509000- 00015
Greenberg, M. R., & Schneider, D. F. (1995). Gender dierences in risk perception:
Eects dier in stressed vs. nonstressed environments. Risk Analysis, 15, 503- 511.
http://dx.doi.org/10.1111/j.1539- 6924.1995.tb00343.x
Holbrook, T. L., Hoyt, D. B., Stein, M. B., & Sieber, W. J. (2002). Gender dierences
in long- term posttraumatic stress disorder outcomes aer major trauma: Women
are at higher risk of adverse outcomes than men.?Journal of Trauma, 53, 882- 888.
http://dx.doi.org/10.1097/00005373- 200211000- 00012
Husain, S. A., Nair, J., Holcomb, W., Reid, J. C., Vargas, V., & Nair, S. S. (1998). Stress
reactions of children and adolescents in war and siege conditions. American Jour-
nal of Psychiatry, 155, 1718- 1719.
Kang, H. K., Natelson, B. H., Mahan, C. M., Lee, K. Y., Murphy, F. M. (2003). Post-
traumatic stress disorder and chronic fatigue syndrome- like illness among Gulf
War veterans: a population- based survey of 30,000 veterans. American Journal of
Epidemiology. 157, 141 - 148. http://dx.doi.org/10.1093/aje/kwf187
Kessler, R. C. (2000). Posttraumatic stress disorder: e burden to the individual and
to society. Journal of Clinical Psychiatry, 61(5), 4- 14.
Khamis, V. (2005). Post- traumatic stress disorder among school age Palestinian
children. Child Abuse & Neglect, 29, 81- 95. http://dx.doi.org/10.1016/j.chia-
bu.2004.06.013
Kuterovac, G., Dyregrov, A., & Stuvland, R. (1994). Children in war: A silent major-
ity under stress. British Journal of Medical Psychology, 67, 363– 375. http://dx.doi.
org/10.1111/j.2044- 8341.1994.tb01804.x
Macksoud, M. S., & Aber, J. L. (1996). e war experiences and psychosocial devel-
opment of children in Lebanon. Child Development, 67, 70- 88. http://dx.doi.
org/10.2307/1131687

PTSD Among Children Living in War Zones 61
Miller, T., El- Masri, M., Allodi, F., & Qouta, S. (1999). Emotional and behavioral
problems and trauma exposure of school- age Palestinian children in Gaza: Some
preliminary ndings. Medicine, Conict and Survival, 15, 368- 378. http://dx.doi.
org/10.1080/13623699908409478
Moisander, P. A., & Edston, E. (2003). Torture and its sequel- - a comparison between
victims from six countries. Forensic Science International, 137, 133- 140. http://
dx.doi.org/10.1016/j.forsciint.2003.07.008
Nader K. O., Pynoos R. S., Fairbanks L. A., Al- Ajeel, M., & Al- Asfour, A. (1993). A
preliminary study of PTSD and grief among the children of Kuwait following
the Gulf crisis. British Journal of Clinical Psychology, 32, 407- 416. http://dx.doi.
org/10.1111/j.2044- 8260.1993.tb01075.x
Palestinian Central Bureau of Statistics. (2009). Population, Housing, and Establishment
Census 2007: Main Indicators by Locality Type. Palestine: Ramallah.
Pynoos, R. S., Frederick, C., Nader, K., Arroyo, W., Steinberg, A., Eth, S., et al. (1987).
Life threat and posttraumatic stress in school- age children. Archives of General Psy-
chiatry, 44, 1057- 1063. http://dx.doi.org/10.1001/archpsyc.1987.01800240031005
Pynoos, R. S., Goenjian, A., Tashjian, M., Karakashian, M., Manjikian, A., Manouki-
an, G., et al. (1993). Post- traumatic stress reactions in children aer the 1988
Armenian earthquake. British Journal of Psychiatry, 163, 239- 247. http://dx.doi.
org/10.1192/bjp.163.2.239
Qouta, S., Punamaki, R. L., & El Sarraj, E. (2003). Prevalence and determinants of
PTSD among Palestinian children exposed to military violence. European Child
and Adolescent Psychiatry, 12, 265- 272. http://dx.doi.org/10.1007/s00787- 003-
0328- 0
Saigh, P. A. (1991). e development of posttraumatic stress disorder following four
dierent types of traumatization. Behavior Research and erapy, 29, 213- 216.
http://dx.doi.org/10.1016/0005- 7967(91)90110- O
Simmons, C.?A. & Granvold, D.? K. (2005). A cognitive model to explain gender dier-
ences in rate of PTSD diagnosis.?Brief Treatment and Crisis Intervention, 5,?290-
299. http://dx.doi.org/10.1093/brief- treatment/mhi021
Smith, P., Perrin, S., Yule, W., Hacam, B., & Stuvland, R. (2002). War exposure
among children from Bosnia- Hercegovina: Psychological adjustment in a
community sample. Journal of Traumatic Stress, 15, 147- 156. http://dx.doi.
org/10.1023/A:1014812209051
abet A. A., & Vostanis, P. (2000). Post traumatic stress disorder reactions in children
of war: A longitudinal study. Child Abuse & Neglect, 24, 291- 298. http://dx.doi.
org/10.1016/S0145- 2134(99)00127- 1
abet, A. A., & Vostanis, P. (1999). Posttraumatic stress reactions in children
of war. Journal of Child Psychology & Psychiatry, 40, 385- 391. http://dx.doi.
org/10.1111/1469- 7610.00456
abet, A. A., Abed, Y., & Vostanis, P. (2002). Emotional problems in Palestinian chil-
dren living in a war zone: A cross- sectional study. Lancet, 359, 1801- 1804. http://
dx.doi.org/10.1016/S0140- 6736(02)08709- 3
abet, A. A., Abed, Y., & Vostanis, P. (2004). Comorbidity of PTSD and depression
among refugee children during war conict.?Journal of Child Psychology and Psy-
chiatry, 45, 533- 542. http://dx.doi.org/10.1111/j.1469- 7610.2004.00243.x
abet, A. A., Abu Tawahina, A., El Sarraj, E., & Vostanis, P. (2008)..European Child &
Adolescent Psychiatry,?17, 191- 199. http://dx.doi.org/10.1007/s00787- 007- 0653- 9