Emotional problems in Palestinian children living in a war zone: a cross-sectional study

doi:10.1016/S0140-6736(02)08709-3

The Lancet

Volume 359, Issue 9320, 25 May 2002, Pages 1801-1804

https://doi.org/10.1016/S0140-6736(02)08709-3 Get rights and content

Summary

Background

Children living in war zones are at high risk of developing post-traumatic stress and other emotional disorders, but little is known about the effect of traumatic events during war. We aimed to assess the nature and severity of emotional problems in Palestinian children whose homes had been bombarded and demolished during the crisis in Palestine, compared with children living in other parts of the Gaza strip.

Methods

91 children exposed to home bombardment and demolition during Al Aqsa Intifada and 89 controls who had been exposed to other types of traumatic events related to political violence completed self-report measures of post-traumatic stress, anxiety, and fears.

Findings

Significantly more children exposed to bombardment and home demolition reported symptoms of post-traumatic stress (p=0·0008) and fear (p=0·002) than controls. 54 (59%) of 91 exposed children and 22 (25%) of 89 controls reported post-traumatic stress reactions of clinical importance. Exposure to bombardment was the strongest socioeconomic predictor of post-traumatic stress reactions (odds ratio 0·25 [95% CI 0·12–0·53], p=0·0008). By contrast, children exposed to other events, mainly through the media and adults, reported more anticipatory anxiety and cognitive expressions of distress (p=0·001) than children who were directly exposed.

Interpretation

Children living in war zones can express acute distress from various traumatic events through emotional problems that are not usually recognised. Health professionals and other agencies coming in contact with children who have been affected by war and political violence need to be trained in detection and treatment of such presentations.

Introduction

The effect of war on children's mental health is well established. Investigators, mainly from the Middle East and the former Yugoslavia, have recorded high rates of post-traumatic stress disorders and other mental health problems and disorders. For example, after the Gulf war, high rates of post-traumatic stress disorders were recorded in Kuwaiti and Kurdish children.1, 2, 3 These rates were especially prominent if children had been displaced from their community, such as in the conflicts in Croatia⁴ and Bosnia.5, 6, 7

Similar findings have arisen from research with families exposed to civil war or other forms of political violence, for example in Burma⁸ and south Sudan.⁹ Because many investigators assessed children when they were refugees, the direct effects of war trauma were difficult to distinguish from the subsequent longstanding effect of socioeconomic adversities.

In a previous study,¹⁰ we investigated the effect of longstanding armed conflict (Intifada, between 1987 and the Oslo peace treaty in 1993) on Palestinian children. Many (41%) reported moderate to severe post-traumatic stress reactions and high rates of anxiety and behavioural problems (27%). Baker¹¹ also established a high frequency of problems such as fears leaving home (28%), fears of soldiers (47%), and nightmares (7%), during the same period of political and military violence. These rates compare with overall prevalence of 10–15% for emotional and behavioural disorders in children in the general population, which can increase up to 20% in regions of socioeconomic adversity.12, 13 As the peace process was consolidated, and despite the lack of intervention, children's reactions from post-traumatic stress disorders had decreased to 10% at 1 year of follow-up. However, many children (21% as rated by parents and 32% as rated by teachers) still presented with other emotional and behavioural problems, which were predicted by the number of violent events experienced in earlier life.¹⁴

In September, 2000, the Al Aqsa Intifada started and continues today. Children and families have been exposed to various traumatic events, ranging from hearing of killing, to bombardment by helicopters in the entire Gaza strip. We aimed to investigate the nature of post-traumatic reactions, anxiety, and fears in children exposed to bombardment during the conflict, by comparison with a group of children not directly exposed to such traumatic events.

Section snippets

Setting and patients

Since the start of the Al Aqsa Intifada, children have been exposed to various traumatic events, often reported by media across the world. Particular events have been bombardment and home demolition. During the 2-month period of data collection (January and February, 2001), 333 homes were demolished and families were evacuated into tents or flats.¹⁵ Highly exposed regions included the borders of the Gaza strip, Rafah border (Salah El Dine gate), Khan Younis (El Toufah area), and Dear El Balah

Results

180 children participated in the study: 91 (51%) who had been exposed to bombardment and home demolition, and 89 (49%) controls who had not. Table 1 shows the main demographic and socioeconomic variables for the two groups. The non-exposed group was much younger than the exposed group (p=0·033; table 1). We also recorded significant differences in paternal and maternal education status (higher education in parents of the non-exposed group than in the exposed group: fathers p=0·0008; mothers

Discussion

The effect of war and political violence on the mental health of children and adults is well established, and usually presents as post-traumatic stress disorder.¹⁰ We have assessed the nature and severity of emotional problems in Palestinian children living in the midst of fighting, but in their own well known environment.

Overall, and in accordance with previous research, post-traumatic stress reactions were both severe and widespread. More than twice as many children exposed to bombardment and

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ArticlesEmotional problems in Palestinian children living in a war zone: a cross-sectional study

Summary

Background

Methods

Findings

Interpretation

Introduction

Section snippets

Setting and patients

Results

Discussion

J Am Acad Child Adolesc Psychiatry

Child Abuse Negl

J Am Acad Child Adolesc Psychiatry

Child Abuse Negl

A preliminary study of PTSD and grief among the children of Kuwait following the Gulf crisis

Br J Clin Psychol

Post traumatic stress disorder in children after the military operation "Anfal" in Iraqi Kurdistan

Eur Child Adolesc Psychiatry

Children in war: a silent majority under stress

Br J Med Psychol

Displaced adolescents in Croatia: sources of stress and post traumatic stress reaction

Adolescence

War trauma and psychopathology in Bosnian refugee children

Eur Child Adolesc Psychiatry

War exposure and maternal reactions in the psychosocial adjustment of children from Bosnia-Herzegovina

J Child Psychol Psychiatry

Burmese political dissidents in Thailand: trauma and survival among young adults in exile

Am J Public Health

The psychological impact of war and the refugee situation on South Sudanese children in refugee camps in Northern Uganda

J Child Psychol Psychiatry

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J Child Psychol Psychiatry

Articles
Emotional problems in Palestinian children living in a war zone: a cross-sectional study