Exposure to War Trauma and PTSD

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Introduction

Children directly or indirectly exposed to war conflictexperience a variety of stressors, and many developboth short-term and long-term post-traumatic stressreactions [5]. Common symptoms and reactions inthe aftermath of a potentially traumatic event includesadness, anger, fears, numbness, feeling jumpy or

jittery, moodiness or irritability, change in appetite,difficulty in sleeping, nightmares, avoidance of situ-ations that are reminders of the trauma, impairmentof concentration, and guilt because of survival or lackof harm during the event [4, 47].

A number of studies have found a high prevalenceof post-traumatic stress disorders (PTSD) amongchildren exposed to war trauma, state-sponsored

A. A. ThabetA. Abu TawahinaEyad El SarrajPanos Vostanis

Exposure to war trauma and PTSD

among parents and children

in the Gaza strip

Accepted: 8 August 2007Published online: 25 March 2008

j Abstract Objective Exposureto war trauma has been indepen-dently associated with posttrau-

matic stress (PTSD) and otheremotional disorders in childrenand adults. The aim of this studywas to establish the relationshipbetween ongoing war traumaticexperiences, PTSD and anxietysymptoms in children, accountingfor their parents equivalent men-tal health responses. Methods Thestudy was conducted in the GazaStrip, in areas under ongoingshelling and other acts of militaryviolence. The sample included 100

families, with 200 parents and 197children aged 918 years. Parentsand children completed measuresof experience of traumatic events(Gaza Traumatic Checklist), PTSD(Childrens Revised Impact ofEvents Scale, PTSD Checklist forparents), and anxiety (RevisedChildrens Manifest Anxiety Scale,and Taylor Manifest Anxiety Scalefor parents). Results Both chil-dren and parents reported a high

number of experienced traumaticevents, and high rates of PTSD andanxiety scores above previously

established cut-offs. Among chil-dren, trauma exposure was signif-icantly associated with total andsubscales PTSD scores, and withanxiety scores. In contrast, traumaexposure was significantly associ-ated with PTSD intrusion symp-toms in parents. Both war traumaand parents emotional responseswere significantly associated withchildrens PTSD and anxietysymptoms. Conclusions Exposureto war trauma impacts on both

parents and childrens mentalhealth, whose emotional responsesare inter-related. Both universaland targeted interventions shouldpreferably involve families. Thesecould be provided by non-gov-ernmental organizations in thefirst instance.

j Key words war trauma parents child PTSD

ORIGINAL CONTRIBUTIONEur Child Adolesc Psychiatry (2008)17:191199 DOI 10.1007/s00787-007-0653-9

ECAP

653

A.A. Thabet A. Abu TawahinaE. El SarrajGaza Community Mental HealthProgrammeEl Rasheed StreetP.O Box 1049Gaza, Palestine, Israel

P. Vostanis (&)University of LeicesterGreenwood Institute of Child HealthWestcotes House, Westcotes DriveLeicester LE2 OQU, UKTel.: +44-116/2252885Fax: +44-116/2252881E-Mail: [email protected]
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terrorism, or interpersonal violence. For example, astudy in countries exposed to widespread politicaltrauma estimated that the prevalence of lifetime PTSDis 37% in Algeria, 28% in Cambodia, 16% in Ethiopia,and 18% in Gaza [11]. The latter area in the MiddleEast has been subject to several studies on childrensrecollection of trauma experiences and their impact

on their mental health. For example, the most com-mon traumatic events reported by Palestinian chil-dren were, seeing victims pictures on television, andwitnessing bombardment and shelling, with betweenone-third and half of the children in different samplesfulfilling criteria for PTSD [34, 44]. They were alsolikely to present with high rates of anxiety ordepressive disorders [43, 44].

Similar evidence on the impact of war trauma hasbeen established for adults by a number of studies[11]. For example, in a study of Rwandans, 24.8% ofadults met symptom criteria for PTSD [31]. In across-sectional survey of war survivors who had

experienced war-related stressors (combat, torture,internal displacement, refugee experience, siege, and/or aerial bombardment) in former Yugoslavia, par-ticipants reported experiencing a mean of 12.6 war-related events, with 22% and 33% having current andlifetime posttraumatic stress disorder (PTSD),respectively, and 10% current major depression [6].

Some studies aimed to identify mediating factorsin the association between war trauma and otherdisorders among children. PTSD rates were particu-larly prominent if children had been displaced fromtheir community, for example during the conflicts inCroatia and Bosnia [2, 23]. Both the type and the

amount of the exposure are important [23, 28]. Otherrisk factors associated with PTSD symptomatologyincluded proximity to the zone of impact [27, 33],degree of life threat [28, 32], and underlying socio-economic hardship [22].

The effect of parental and family variables has alsobeen investigated. Children exposed to war conflicthave been foundto be protectedby family cohesion [24,25], positive home environment, and mothers per-ceptions of a functional family [53]. Previous studieshave established an association between parents andchildrens general psychopathology following war andpolitical conflict [15, 35, 39]. This relationship can vary

at different stages in the childs development [52]. Re-cent studies have specifically examined the mecha-nisms underlying links in PTSD symptoms withinfamilies. Qouta et al. [34], for example, suggested thatthe impact of maternal responses on children is dif-ferent for the PTSD subscales of intrusion and avoid-ance. Better understanding of how children and parentsrespond to similar conflict is important for the devel-opment of interventions, therefore this was the ratio-nale for this study.

The aims were to investigate: (a) the independentassociation between exposure to war trauma withparents and childrens mental health symptoms; (b)whether the association between trauma exposure andchild mental health problems remains after account-ing for parental mental health responses; and (c)whether this association applies equally to PTSD,

anxiety and other mental health problems.

Methods

In order to address the previous aims, the followingresearch hypotheses were tested:

(a) Exposure to war trauma would be independentlyassociated with PTSD among parents and chil-dren.

(b) This association for children would remain afteraccounting for their parents emotional re-

sponses.(c) The association between trauma exposure wouldonly apply to PTSD, but not to other anxiety ormental health problems.

j Setting and sample

The Gaza Strip is a narrow elongated piece of land,bordering the Mediterranean Sea between Israel andEgypt, and covers 360 km2. It has high populationdensity. About 17% of the population lives in the northof the Gaza Strip, 51% in the middle, and 32% in the

south area. There is high unemployment, socio-eco-nomic deprivation, family overcrowding, and short lifeexpectancy. Nearly two-thirds of the population arerefugees, with approximately 55% living in eightcrowded refugee camps. The remainder lives in villagesand towns. Since September 2005, the population of theGaza Strip has been exposed to regular incursions andshelling, resulting in at least 200 deaths and many moreinjuries, in the last 6 months alone.

The reports of the World Bank and the PalestinianCentral Bureau of Statistics showed that the unem-ployment rate reached 25.3% in the Palestinian ter-ritory during the first quarter of 2006, distributed by

21.4% in the West Bank and 34.1% in the Gaza Strip.The estimated poverty rate among Palestinianhouseholds in the Palestinian territory during thesecond quarter of 2006 had increased dramatically to65.8%, and distributed by 65% in the West Bank and87.7% in the Gaza Strip. Just over half (55.6%) of thehouseholds were suffering deep poverty [29].

The study population included 100 families livingin areas exposed to shelling, in the north and east ofthe Gaza Strip. Families with two children aged from 9

192 European Child & Adolescent Psychiatry (2008) Vol. 17, No. 4 Steinkopff Verlag 2008
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to 18 years were included. A total number of 200parents (100 mothers and 100 fathers) and 197 chil-dren agreed to take part in the study. Families wereselected randomly from two villages, one camp, andone city. The selection was based on the proximity ofthe area to regular shelling, which was defined ashouseholds within visible distance of shelling (dust

and pieces of shells). One street was selected in eacharea, and every other household that fulfilled thefamily selection criteria. In larger buildings, one flatfrom each floor was selected (area of Beit Lahia).Families were included if they consisted of both par-ents, with one boy and one girl, aged between 9 and18 years, and had been in the area for the last year. Ifa family had both a boy and girl who fulfilled theselection criteria, each gender was selected alterna-tively. The same applied to age order within the sib-lings group. Families were approached until 100agreed to participate, which was a convenience sam-ple, partly based on previous studies in this field.

The data collection was carried out by three trainedprofessionals of clinical psychology background, un-der the supervision of the first author. The data wascollected during June 2006. Families were interviewedin their homes. One of the difficulties of this studywas that, throughout the interviews, there was fre-quent shelling of the selected areas, for which reasonthe interviews had to be discontinued and repeatedlater by the same interviewers, although the two setsof interviews for the same family (incomplete andcomplete) were not compared, with the latter datasetbeing used in the analysis.

j Measures

These were selected on the basis of previous use insimilar studies across different cultural groups, andtheir standardization. As the instruments had beenpreviously used in this population by the researchteam, no changes in wording were made duringtranslation but, if difficulties were encountered in theunderstanding of certain statements, these were ex-plained or discussed by the researchers.

Children

The Gaza Traumatic Events Checklist was used,describing the most common traumatic experiencesfamilies could have faced in the Gaza Strip duringthe previous 6 months, including shelling of theirarea of residence. The checklist was revised from aversion used in earlier research [43, 44], adaptedfor the nature of traumatic events occurring duringthe current conflict.

The Childrens Revised Impact of Events Scale(CRIES-13) [19, 38] measured symptoms of post-

traumatic stress disorder (PTSD) over the previous6 months. This included all eight items of the ori-ginal Impact of Events Scale, as well as five itemsderived from the arousal criteria in the DSM-IVclassification [3]. Individual items were ratedaccording to the frequency of their occurrenceduring the past week (none = 0, rarely = 1, some-

times = 3, a lot = 5) and in relation to a specifictraumatic events written at the top of the scale. Inthis study the revised IES was translated fromEnglish to Arabic and back translated. A cut-offscore of 30 and above has been found to indicatethe likelihood of presence of PTSD [30]. A totalscore was provided, as well as subscales scores forintrusion, arousal and avoidance PTSD symptoms.

The Revised Childrens Manifest Anxiety Scale(RCMAS) [36] is a standardised 37-item self-reportquestionnaire for children of 619 years. It mea-sures the presence or absence of anxiety-relatedsymptoms (yes/no answers) in 28 anxiety items

and 9 lie items. A cut-off total score of 19 has beenfound to predict the presence of anxiety disorder[37].

The Strengths and Difficulties Questionnaire (SDQ)[17] was completed by parents on their childrensbehavioural and emotional functioning. This stan-dardized questionnaire includes 25 items on a 02scale. The 25 SDQ items are grouped in the scales ofhyperactivity, emotional, conduct, and peer rela-tionships problems, as well as a prosocial scale. Ascore is estimated for each scale and a total diffi-culties score for the four problem scales. The totaldifficulties score, which did not include the proso-

cial items, was used in this study as a measure ofgeneric psychopathology. The SDQ has previouslybeen used in the Gaza child population by the re-search group [45].

Parents

The following measures were completed indepen-dently by the childs parents:

The Gaza Traumatic Checklist was also completedby parents. This includes the same items as forchildren.

The Posttraumatic Stress Disorder Checklist forparents (PCL) contains 17 items adapted from theDSM-IV [3] PTSD symptom criteria. Respondentsare asked to rate on a 5-point Likert scale (1 = notat all to 5 = extremely) the extent to which symp-toms troubled them in the previous month. A totalscore was provided, as well as subscales scores forintrusion, arousal and avoidance PTSD symptoms.The PCL has been standardized [8]. The diagnosisrequires the presence of one re-experiencing, three

A.A. Thabet et al. 193War trauma and PTSD in parents and children
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avoidance and two hyperarousal symptoms, witheach symptom being defined as positive if scored as3 or above.

The Taylors Manifest Anxiety Scale (MAS) [41]measures symptoms of chronic anxiety. We usedthe Arabic version [40] with 50 items rated as yes/no. Scores can be classified as 026 (no anxiety),

2732 (mild anxiety), 3340 (severe anxiety), and41 and above (very severe anxiety). The latter twocategories were grouped together, as indicatinganxiety symptoms of clinical significance.

j Statistical analysis

Frequencies and descriptive statistics are initiallypresented, including likely rates of psychiatric disor-ders, according to previously established cut-offscores. Between-group differences on questionnairescores (trauma exposure and psychopathology) were

estimated by non-parametric tests (MannWhitneyfor two groups and KruskalWallis for multiplegroups), as the questionnaire data was not normallydistributed. The relationship between childrens andparents PTSD scores (also between respective anxietyscores) was estimated by Spearman rank correlationtest. The association between exposure to trauma(total score as independent variable) and psychopa-thology in either the child or the parent was initiallyinvestigated by a series of univariate linear regressionanalyses, with the psychopathology score (total PTSDor PTSD subscale or total anxiety score) as thedependent variable. In a series of multivariate linear

regression models all traumatic events were enteredas covariates, with each measure of psychopathology(child or parent) as the dependent variable, to test outthe predictive value of particular types of trauma.Finally, in two multiple liner regression models,trauma exposure and parental emotional scores(PTSD or anxiety) were entered as covariates, with

childrens emotional scores (PTSD or anxietyrespectively) as the independent variable.

Results

j Sociodemographic data

The boys mean age was 12.8 years (SD = 2.5), andthe girls mean age was 13.2 (SD = 2.51). Palestinianfamilies consisted of large number of children, as 39(19.5%) had 4 or less children, 92 families (46.0%)had 57 children, and 69 families (34.5%) had 8 ormore children. About 48 children (24%) lived in thecity, 102 (51%) lived in villages, and 50 children(25%) lived in refugee camps. The fathers mean agewas 43.6 years (SD = 7.14), and mothers mean agewas 39.48 years (SD = 6.83). The majority of families(130, or 65.0%) had a very low monthly income of lessthan $265, 27 families (13.5%) had an income of

$271560, and 43 families (21.5%) had a monthlyincome of more than $560.

j Traumatic events experienced by children

The most frequently reported traumatic events were,watching mutilated bodies and wounded people onTV (98.5%), witnessing signs of shelling on theground (94.9%), and hearing shelling of the area byartillery (92.9%) (Table 1). Children experienced amean number of eight traumatic events (SD = 2.55).Boys were more significantly exposed to trauma than

girls (MannWhitney test: z = 1.95, P = 0.050). Chil-dren in high income families experienced significantlyless traumatic events than the other two incomegroups (KruskalWallis test, chi-square 9.18, df = 2,P = 0.010). There was no association between chil-drens age and exposure to trauma (Spearman rankcorrelation r = )0.071, P = 0.32).

Table 1 Type of traumaticexperiences by parents and children Traumatic events Parents

(N = 200)Children(N = 197)

No % No %

Watching mutilated bodies and wounded people on TV 197 98.5 193 98.5Witnessing the signs of shelling on the ground 190 95 186 94.9Hearing the sonic sounds of the jetfighters 188 94 176 89.8Witnessing bombardment of other homes by airplanes and helicopters 186 93 170 86.7Hearing shelling of the area by artillery 186 93 182 92.9Witnessing firing by tanks and heavy artillery of neighbours home 174 87 146 74.5Hearing about killing of a friend 167 83.5 139 71.3Witnessing assassination of people by rockets 158 79 147 75.0Hearing about killing of a close relative 141 70.5 119 61.0Witnessing firing by tanks and heavy artillery on your home 127 63.5 146 74.5

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j Childrens psychopathology and associationwith trauma exposure

The mean scores on the mental health measures arepresented in Table 2. Children reported differentreactions to traumatic events on the CRIES-13, themost common reactions being: insomnia (40.5%),exaggerated startle (39%), and trying to remove

memories from their mind (39%). Considering theCRIES-13 cut-off score of 30 [29], 138 children out of197 (70.1%) were likely to present with PTSD, or 69%of the boys and 71.1% of the girls.

According to a cut-off score of 19 or more on Re-vised Childrens Manifest Anxiety Scale, 35 children(33.9%) were rated as having anxiety symptoms oflikely clinical significance. According to a SDQ cut-offscore of 17 or above, 77 children (42.7%) were rated ashaving significant mental health morbidity by theirparents. Children living in inner-city areas were ratedsignificantly higher on total SDQ scores (broad mentalhealth problems)KWallis test: chi-square = 6.25,

df = 2, P = 0.044). Childrens age was significantlyassociated with total PTSD (r = 0.24, P = 0.001) andanxiety symptoms (r = 0.22, P = 0.003).

In a univariate linear regression analysis, exposureto traumatic events was significantly associated withPTSD symptoms (CRIES-13 scores): B = 1.31, 95%CI = 0.482.13, P = 0.002. When this analysis wasrepeated separately for each PTSD subscale, theassociation remained significant for intrusion symp-toms (B = 1.11, P < 0.001), avoidance (B = 0.36,P = 0.047), and arousal symptoms (B = 0.86,P < 0.001). When each traumatic event was entered asan independent variable in a multiple regression

model (without other independent variables in themodel), with total CRIES-13 scores as the dependentvariable, no single traumatic event was significantlyassociated with PTSD symptoms.

The number of experienced potentially traumatiz-ing events was also associated with total anxiety(RCMAS) scores: B = 0.53, 95% CI = 0.170.89,P = 0.004. In contrast, trauma exposure was notassociated with general mental health problems (SDQtotal scores): B = 0.070, 95% CI = )0.57 to 0.43.

j Traumatic events experienced by parents

Parents reported similar frequencies of traumaticevents to their children (Table 1). The most commontraumatic events were, watching mutilated bodies andwounded people on TV (98.5%), witnessing the signs ofshelling on the ground (95%), hearing sonic sounds of

jetfighters (94%), and witnessing bombardment ofother homes by airplanes and helicopters (93%). Par-ents reported a mean number of 8.5 traumatic events(SD = 1.68). As among children, parents in the highincome group experienced less traumatic events thanthe other two income groups (KWallis test: chi-square = 11.69, df = 2, P = 0.03). Parents and chil-drens ratings of exposure to trauma were significantlycorrelated (Spearman coefficient r = 0.25, P < 0.001).

j Parents psychopathology and association withtrauma exposure

Parents reported different reactions to traumaticevents, the most common reactions being: flashbacks(68.5%), intrusive memories (59%), and amnesia(51%). Considering a cut-off score of 50 or more onthe PTSD scale, 120 parents (60%) had symptoms ofpotential clinical significance. Considering a cut-offscore of 33 or more on the Taylor Anxiety Scale, 52parents (26.0%) reported severe to very severe anxietysymptoms. There was no significant difference onPTSD or anxiety scores between the parents. Mothersreported higher anxiety scores (MWhitney test:z = 1.84, P = 0.065) and PTSD intrusion scores thanfathers (z = 1.80, P = 0.071), although neither trend

reached statistical significance. Parents age was sig-nificantly associated with PTSD symptoms (r = 0.17,P = 0.013), but not with trauma exposure or anxietysymptoms.

Parents and childrens ratings of PTSD symptomswere significantly correlated for the intrusion(Spearman r = 0.34, P


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multiple regression model, with total PTSD scores asthe dependent variable, two events were significantlyassociated with parents PTSD symptoms:

Witnessing bombardment by airplanes and heli-copters: B = 8.36, 95% CI = 0.7415.96, P = 0.032;and Witnessing firing of their own home by tanks andheavy artillery: B = 4.60, 95% CI = 0.828.39,P = 0.017.

The total number of experienced traumatic eventswas not associated with anxiety symptoms in parents

(B = 0.21, 95% CI = )0.34 to 0.75, P = 0.45).

j Relationship between trauma exposure, parentaland child psychopathology

The association between trauma exposure and eitherPTSD or anxiety symptoms in children, was subse-quently tested accounting for equivalent parents re-sponses, in two multiple linear regression models.Childrens PTSD symptoms were predicted by bothtrauma exposure, as measured by the Gaza TraumaticEvents Checklist (B = 1.36, 95% CI = 0.542.17,P = 0.001) and parents PTSD scores (B = 0.18, 95%

CI = 0.0380.33, P = 0.014) (Table 3two indepen-dent variables entered, both reported in the table).Similarly, childrens anxiety symptoms were predictedby both trauma exposure (B = 0.39, 95% CI = 0.070.73, P = 0.018), and parents anxiety scores(B = 0.30, 95% CI = 0.210.39, P < 0.001). Theaddition of parents gender or the childrens age as acovariate, because of their independent associationwith some of the dependent variables, did not alterthe findings. The low R2 values indicate that otherfactors may have been involved, but not captured bythis study.

Discussion

As with other types of acute and chronic trauma,exposure to war and political conflict has been found toindependently impact on adults and childrens mentalhealth, predominantly associated with internalizingdisorders such as PTSD, anxiety and depression.Studies in recent years also indicated the associationbetweenparental and child responses [35, 39], although

little is known on the underlying mechanisms, i.e.whether these are the same as for other types of trauma[14], or whether different mechanisms operate fordifferent types of psychopathology. This study ex-plored further this relationship in relation to PTSD andanxiety symptoms among Palestinian exposed toshelling and other forms of military violence. One dif-ference from previous studies was that exposure totrauma was ongoing duringthe data collection, ratherdata on mental health symptoms being collected after

the cessation of conflict. This might be relevant to someof the findings, particularly those concerning parentsresponses.

The impact of parental emotional responses onchildrens mental health is neither unique not specificto this kind of trauma. This association has previouslybeen established among parents and children exposedto other types of acute or chronic adverse life events,although different mechanisms have been shown tounderpin this relationship. For example, parents suf-fering from psychiatric disorders have been found toaffect their childrens emotional and behaviouralfunctioning predominantly through impaired par-

enting capacity [7, 18]. Exposure to domestic vio-lence, family breakdown and homelessness have bothdirect impact on children, as well as indirectlythrough their mothers maladaptive coping and par-enting strategies [21, 48].

Exposure to war trauma was significantly associ-ated with all measures of PTSD, including its threesubscales, and with anxiety. The impact appearedrelated to the total number and severity of events,without any single event predicting PTSD symptoms.The lack of association between trauma and generalmental health problems, predominantly of behavio-ural and social nature, as measured by the SDQ, was

not surprising, as such generic measures usually re-flect longstanding problems (in behavioural, emo-tional and social functioning) which are related toparenting, school or developmental difficulties, ratherthan acute trauma-induced distress [45, 50]. Suchmental health problems may have been related tolongstanding adversities and life events, which werenot measured in this study, but these, were not foundto be specifically associated with exposure to trauma.The latter may have a cumulative effect on previous

Table 3 Association between exposure to trauma, parental responses, and childrens PTSD and anxiety symptoms (multiple linear regression model)

Model Independent variable B 95% CI Significance

Model of association with childrens PTSD symptoms(total CRIES-13 scores as dependent variable)

Childrens trauma exposure 1.36 0.552.18 0.001

R2 = 0.076 Parents PTSD symptoms 0.19 0.040.33 0.014

Model of association with children anxiety symptoms(total RCMAS scores as dependent variable)

Childrens trauma exposure 0.40 0.070.73 0.018

R2 = 0.21 Parents anxiety symptoms 0.30 0.210.39


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risk factors [49]. This mechanism has been found tooperate in children with oppositional defiant disor-ders, but not neurodevelopmental conditions such asADHD [16]. In contrast, trauma exposure appeared tobe specifically associated with anxiety and PTSDpresentations. Future longitudinal research wouldimprove the understanding of such mechanisms be-

tween different types of traumatic or other life events,and different kinds of psychopathology.

Parents and children had experienced high rates ofsimilar events. As previous trauma research hasshown, children can be affected directly by exposureto trauma and by adults reactions, i.e. through pri-mary and secondary traumatization [12]. Somemechanisms of direct impact have been found toapply independently to both parents and childrensuch as loss of control, loss of self-image (particularlyif family members have been injured), fears of deathand harm, and isolation from their social networks[9]. Children can also experience increased depen-

dency and fear of abandonment [9]. Parental reac-tions can be influenced by past traumas [10], and theycan in turn adversely affect children through changesin their parenting capacity and family functioning [4].For example, Henry et al. [18] established tighterparental monitoring and reported beliefs on theimportance and purpose of the family following the11th September terrorist attacks in the US. The pop-ulation of our study was faced with additional adversecircumstances such as unemployment, overcrowding,occupation, and proximity to war activities, all ofwhich factors are likely to impact on families copingstrategies and well-being.

Unlike earlier studies, the most common traumaticevent in recent research with this population [33], hasbeen watching mutilated bodies on television. Al-though this finding per se does not demonstrate aspecific effect of media on families and their children,it is important to consider potential implications, asPalestinian families spend increasing time watchingnews and other programmes about the conflict,without alternative leisure or other activities. Forexample, there could be a differential impact betweenwatching or being told about events on television, andhaving experienced those events. In an earlier study,for example, we found that children whose houses had

been demolished by shelling in the Gaza Strip sig-nificantly reported more PTSD and phobic symptoms,while children living in non-bombarded areas weremore likely to report anticipatory anxiety symptoms[43].

The pattern of parents and childrens emotionalresponses was somewhat different, i.e. trauma expo-sure was particularly associated with PTSD intrusionsymptoms. Specific events, namely witnessing firingof their home by tanks and heavy artillery, and

bombardment by aircrafts and helicopters, werefound to have a specific impact on parents. In anearlier study, Laor et al. [25] found that families re-sponses to a missile attack were explained bydestruction of their house and displacement, ratherthan by mere distance from the missile impact. Thenature of the traumatic events might have been

implicated in the different mechanisms of affectingparents during this conflict. Qouta et al. [35] partic-ularly highlighted the sudden and non-predictableviolence that characterizes the conflict in the GazaStrip, i.e. shelling, bombardment and incursions;being prevented from helping wounded familymembers; and burying their dead with dignity andaccording to their religious rules.

Intrusion symptoms such as fears and nightmaresmight develop early as an acute response amongpeople being in a continuous state of high alert,while avoidance symptoms might develop later, or inresponse to different types of traumatic situations.

Avoidance could also operate as a coping strategy insimilar circumstances. As the political conflict in theregion of the study is relatively chronic, with inter-mittent phases of escalation rather than a completepeace process, its impact on children may thus bedifferent from a new emerging threat.

Interviewing during a period of such exposure isnot necessarily different from interviewing vulnerablechildren who experience family or community vio-lence and abuse, i.e. there is no evidence that thesecould cause harm. However, there could be implica-tions on interviewing techniques that could elicitchildrens experiences. For example, Henry et al. [18]

found a variation of responses, depending on theexplicit (or not) reference of the interview to specifictraumatic events (in that study, these were terroristattacks).

The rates of PTSD and anxiety symptoms amongparents and children were of sufficient severity torequire assessment and intervention. Parents andchildrens scores were significantly correlated forPTSD intrusion and arousal (but not for avoidance),as well as for anxiety symptoms. Overall, parentalresponses were found to contribute to childrensPTSD and anxiety presentations. Previous studiesestablished a stronger impact of maternal responses

on younger (pre-school) children [16, 41]. Althoughwe did not find age differences in this study, thesample was much older (918 years) than the previ-ous cohorts.

The study has a number of limitations. A longitu-dinal component may have helped understand betterthe changes in psychopathology among children andtheir parents, in relation to changes in trauma expo-sure. As the study focused on the measurement ofacute trauma-induced stress, which is relatively nar-

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row, the future inclusion of potentially confoundingfactors such as parenting ability, family functioning,support networks, coping strategies, and culturalperceptions of trauma or mental health [26], couldalso improve the understanding of such mechanisms.Other constraints were reliance on self-reports, andlack of information on families perceptions of other

important factors such as work and financial condi-tions, separation from relatives, activism, andharassment.

Although beyond the direct remit and aims of thestudy, the findings have implications for the devel-opment of interventions and services. Involving par-ents in the assessment and intervention is importantin promoting consistent strategies, responses toexternal adversities, and relative stability within theimmediate family group, while avoiding if at all pos-sible separation with their children [5]. This level offamily input is not realistic for specialist mentalhealth services in circumstances of widespread con-

flict [20], but could form the objective of non-gov-ernmental organizations (NGOs), as part of universalor targeted initiatives during and after the crisis.Families can be involved at different levels of phasedpsychosocial programmes, which aim at minimaldisruption of protective factors, re-establishment ofremaining protective factors, and provision of com-pensatory supports [1]. Group psychoeducationalprogrammes are a cost-effective mean of reaching alarge number of families by a limited number of staff.

More focused interventions are also emerging andappear promising such as multi-family groups, com-bining education, support and therapeutic tasks [51].

Dybdahl [13] described and evaluated a psychosocialintervention for mothers following the war in Bosnia,whose aim was to promote young childrens devel-

opment and well-being through parental involvement,support and education. Particular importance wasattributed to the motherchild interaction during thehealing process. Positive outcomes were establishedin several aspects of functioning, namely mothersmental health, childrens weight gain and psychoso-cial functioning.

As such programmes usually target resettled pop-ulations, or the local community after terminationof the acute conflict, when a considerable degree ofsafety and stability has been achieved, there is lackof evidence or consensus on whether and how torespond during external conflict, particularly whenthis is longstanding and there is no migration orsignificant population movement (such as the case offamilies in the Gaza Strip and the West Bank). In aprevious trial during the same conflict, we found nosignificant difference in the impact of a relativelyinactive group debriefing crisis intervention for chil-dren, compared to group education on post traumatic

symptoms, or no intervention [46]. One potentialexplanation for this finding was the non-involvementof parents in the intervention, who may have main-tained childrens emotional distress. More serviceinitiatives and studies are needed in areas of actualongoing conflict. Previous post-conflict programmesand interventions could be adapted to the Palestiniancontext, or integrated with existing international ini-tiatives such as offered by Unicef, with subsequentevaluation, which often lacks from similar non-gov-ernmental programmes.

j Acknowledgments We are grateful to the families and childrenwho participated in this study, for their openness in sharing suchdifficult issues. Also, we wish to thank the team that collected thedata under shelling and enormous difficulties.

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Exposure to War Trauma and PTSD