“Prevalence and determinants of PTSD among

Palestinian children exposed to military violence”

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj;

European Child & Adolescent Psychiatry, 2003

The prevalence and determinants of PTSD were assessed among 121

Palestinian children (6-16 years; 45% girls and 55% boys) living in the area of
bombardment. The mothers (21-55 years) and the children themselves reported
their exposure to military violence (being personally the target of violence or
witnessing it towards others) and symptoms of posttraumatic stress disorders
(PTSD: intrusion, avoidance and hypervigilance). The results showed that 54% of
the children suffered from severe, 33.5% from moderate and 11% from mild and
doubtful levels of PTSD. Girls were more vulnerable; 58% of them suffered from
severe PTSD, and none scored on the mild or doubtful levels of PTSD. The
child’s gender and age, mother’s education and PTSD symptoms were
significant, and the exposure to traumatic experiences marginally significant
determinants of children’s PTSD symptoms. The most vulnerable to intrusion
symptoms were younger girls whose mothers showed a high level of PTSD
symptoms, whereas those most vulnerable to avoidance symptoms were children
who had personally been targets of military violence and whose mothers were
better educated and showed a high level of PTSD symptoms. The results are
discussed in the context of military violence inferring with the protective function
of family and home.

Key words: Traumatic events- PTSD – Palestinians – children – mothers

 “Associations between self and other
representations and posttraumatic adjustment
among political prisoners”

Jari Salo, Raija-Leena Punamaki, and Samir Qouta;

Anxiety, Stress and Coping, 2003, 1-19.

The content and structure of self and other representations and their association
with posttraumatic stress symptoms, somatic symptoms, and positive growth
were studied among 117 Palestinian male political prisoners. Further, the
associations between the representations and the severity of trauma and the
post-detention conditions (such as education, place of residency and
employment), and the role of representation patterns as a moderator between
trauma exposure and symptoms was studied. Cluster analysis identified three
representation patterns based on participants’ descriptions of their spouse and
themselves, and of childhood relationships with their mother and father.
Representation patterns differed in negative vs. positive content and in the levels
of differentiation and conceptual maturity: The Malevolent Others and Defeated
Self representation pattern was characterized by very negative content, and poor
differentiation and conceptual maturity in all descriptions; the Moderate Parents
and Negative Spouse pattern was characterized by an average level of content
negativity/positivity and reasonable levels of differention and conceptual maturity,
and the Benevolent Spouse and Ambitious Self pattern showed the most positive
content and the highest levels of differentiation and conceptual maturity in
spouse and self descriptions. The results further showed that the self and other
representations associated with both posttraumatic stress symptoms and the
positive growth, but not with the somatic symptoms. The men with Malevolent
Others and Defeated Self representation pattern reported higher levels of
posttraumatic stress symptoms and lower levels of positive growth than those
with other representation patterns. The representation patterns did not differ
according to the severity of trauma or post-detention conditions. Finally, the self
and other representations did not moderate between severe torture and ill-
treatment and symptoms.
 “The role of psychological defenses in
moderating between trauma and post-traumatic
symptoms among Palestinian men”

Raija-Leena Punamaki, Katri Kanninen,

Samir Qouta, Eyad El-Sarraj;
International Journal of Psychology, 2002, 37 (5), 286-296.

Psychological defenses are conceptualized as protective processes that help

individuals to maintain their integrity in the face of threat and danger.
Accordingly, their role in defending trauma victims from post-traumatic symptoms
was examined. The sample considered of 128 Palestinian male political ex-
prisoners who had reported various degrees of torture and ill-treatment. The first
aim was to analyze the dimensionality and distribution of different defense
mechanisms. The second was to examine which defenses would moderate the
association between the reported torture and ill-treatment and the post-traumatic
symptoms (PTSD). Third, the direct association between reported torture and ill-
treatment and defenses and between the defenses and symptoms were
explored. Defense mechanisms were assessed by a 40-item version of the
Defense Style Questionnaire (DSQ), and Post-traumatic symptoms by the
Harvard Trauma Questionnaire (HTQ), and experiences of torture and ill-
treatment by a sale developed for that purpose. The results show, first, that men
used predominantly mature defenses such as anticipation, sublimation,
suppression, and rationalization, but also relatively frequently somatization and
dissociation, which are characteristic responses among trauma victims. Second,
the principal component analysis revealed four defense dimensions,
differentiated by the level of maturity and the approach to reality: the mature
reality-distorting consciousness-limiting, the immature reality-escaping, and the
immature reality-distorting defense. Third, against our hypothesis, the moderating
analyses indicated that the reported torture and ill-treatment were relatively more
associated with vigilance, avoidance, and intrusion symptoms if men used
consciousness-limiting defenses. Yet as expected, the mature reality-based
defenses did not show a protective effect. Furthermore, a high level of reported
torture and ill-treatment was associated with a low level of the mature reality-
based defenses but not with a high level of immature defenses. Last, similarly to
earlier studies, the immature reality-distorting and immature reality-escaping
defenses associated directly with high, and mature reality-based defenses with
low, levels of PTS-symptoms.
 “Resiliency Factors Predicting Psychological
Adjustment after Political Violence among
Palestinian Children"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj;

International Journal of Behavioral Development, 2001, 25 (3), 256-
267.

The effects of cognitive capacity, perceived parenting, traumatic events and

activity, which were first mentioned in the midst of the political violence of the
Intifada in 1993, were examined on post-traumatic stress disorder (PTSD),
emotional disorders, school performance, and neuroticism three years later in
more peaceful conditions among 86 Palestinian children of 14.04 ± .79 years of
age. The results showed, first, that PTSD was high among the children who had
been exposed to a high level of traumatic events and had responded passively
(not actively) to Intifada violence. Discrepant perceived parenting was also
decisive for adjustment: children who perceived their mothers as highly loving
and caring but their fathers as not so showed a high level of PTSD. High
intellectual but low creative performance was also characteristic of the children
suffering from emotional disorders. Second, the hypothesis that cognitive
capacity and activity serve a resilience function if children feel loved and non-
rejected at home was confirmed. Third, neuroticism decreased significantly over
the three years, especially among the children who had been exposed to a high
number of traumatic events.
 “Mental flexibility as resiliency factor among
children exposed to political violence”

Samir Qouta, Eyad El Sarraj and Raija-Leena Punamaki

International Journal of Psychology, 2001, 36 (1), 1-7.

The research focused on mental flexibility versus rigidity in explaining

psychological adjustment in the violent conditions of Intifada, and in more
peaceful times 3 years later, among 86 Palestinian children. A picture test based
on Brunswik (1949) was applied to measure flexible-rigid cognitive style, and
neuroticism, self-esteem, emotional disorders, and PTSD were used as outcome
variables. Results revealed a moderating role of mental flexibility by showing that
children were protected from negative long-term consequences of traumatic
events if their perception indicated mental flexibility. However, in the midst of
violence mental flexibility was not associated with good psychological
adjustment. Mental flexibility was, in turn, determined by environmental and
cognitive factors. The more intelligent and less exposed to traumatic events
children were, the higher mental flexibility they showed.
 “Health of Children in War Zones: Gaza Child
Health Survey”

Thomas Miller,
Assisted by Mustafa El-Masri and Samir Qouta, 2000

The Gaza Child Health Survey (GCHS) was conducted as a school-based,

randomized, point prevalence survey of Palestinian children aged 6 and up. The
main aim of the survey was to determine the prevalence rates of emotional and
behavioral health and physical health of 669 children and their families living in
Gaza Strip. Also, an attempt was made to understand the relationship between
environment factors (e.g. trauma exposure, maternal depression etc.) and mental
and physical health outcomes. The main emotional and behavioral outcomes
assessed included: attention deficit hyperactivity disorder (ADHD), conduct
disorder (CD), emotional disorder (ED) and posttraumatic stress disorder
(PTSD).

The GCHS was one of the three health surveys conducted by Health Reach (now
the War and Health Programme), McMaster University in the Former Yugoslavia,
Sir Lanka and Gaza. The survey design stage of the Gaza survey began in 1994
and data collection occurred between January to May of 1996.

The GCHS was conducted by an international team of researchers in psychiatry,

pediatric, family medicine, psychology, anthropology, and statistics. A two-stage
sampling method was used where stage one involved randomly selecting school
from a list of all the public, private and UNRWA schools in Gaza. Stage two
involved randomly selecting students from each school. Interviews of main care
givers and youth were conducted at home; teacher interviews and physical
health assessments were conducted in the schools.
 “An Epidemiological Study in the Prevalence of
Stress Related Psychiatric Disorders among
Palestinians in the Gaza Strip"

Samir Qouta, Eyad El-Sarraj, and Mustafa El-Masri.

1998

The goal of this study was to provide an overall profile of mental health in the
Gaza Strip, through three specific objectives: to assess the extent and nature of
exposure to trauma among Gazans, to identify the psychological consequences
of trauma and the prevalence of stress-related psychiatric disorders, and to
identify different risk factors associated with psychiatric disorders. Post Traumatic
Stress Disorder was the most common diagnosis, occurring in 14.7% of refugees
and 11.7% of citizens. 36.6% reported at least one type of maltreatment during
their childhood, most commonly verbal abuse by parents and elder family
members; 42.2% had witnessed the death of a family member, while 35.1% had
witnessed violent clashes with the Israeli army.
 “House Demolition and Mental Health: Victims
and Witnesses”

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj;

Journal of Social Distress and the Homeless, 1997, 6 (3), 203-211.

The research examines the immediate effects of losing one's home and
witnessing the demolition of others' houses on the mental health of Palestinian
adults and children. The loss group consisted of 47 adults whose homes were
demolished, the witness group of 24 adults who witnessed the house demolition,
and the control group of 33 adults. The groups were compared for their anxiety,
depression and paranoiac symptoms. In addition, 38 children in the loss group,
36 children in the witness group and 50 children in the control group were
compared for their psychological symptoms. The results showed that adults who
were exposed to house demolition showed a higher level of anxiety, depression
and paranoiac symptoms than the witness and control groups. The children in
the loss group showed a higher level of psychological symptoms than the
children in the witness and control groups. The witness group differed from the
control group in having more depression among women and more psychological
symptoms among children. Women suffered more from anxiety, depression and
paranoiac symptoms than men in the loss and witness groups but not in the
control group.
 “Relationships between Traumatic Events,
Children's Gender, and Political Activity, and
Perceptions of Parenting Styles"

Raija-Leena Punamaki, Samir Qouta, and Eyad El-Sarraj;

International Journal of Behavioral Development, 1997, 27 (1), 91-
109.

The associations between traumatic events, children's gender and political

activity, and parenting styles were examined among 108 Palestinians of 11-12
years of age. The results showed that the more the children were exposed to
traumatic events, the more they perceived both their parents as strictly
disciplining, rejecting, and hostile, and their mothers as more negatively
evaluating. The boys perceived both their parents as treating them more
negatively than the girls did. Affectionate parenting, such as intimacy and love,
for its part, was not associated with traumatic events, and did not vary according
to the child's gender or political activity. The gender of the child affected the
association between traumatic events, political activity, and perceived parenting.
Traumatic events increased perceived parental rejection and hostility only among
the boys, and perceived strict disciplining only among the girls. Although
politically active children perceived both of their parents as more negative in
general, in the families exposed to a high level of traumatic events passive boys
perceived their fathers as more rejecting and hostile than active boys did. It is
suggested that mothers and fathers rear girls restrictively and with greater
attention, and boys with rejection, when the family faces traumatic events. In
exposed families, fathers also tend to discourage boys' political passivity and
apparently encourage activity.
“Models of Traumatic Experiences and Children's
Psychological Adjustment: The Roles of
Perceived Parenting and the Children's Own
Resources and Activity"

Raija-Leena Punamaki, Samir Qouta and Eyad El-Sarraj;

Child Development, Vol. 64, (4), 718-728, 1997.

The relations between traumatic events, perceived parenting styles, children's

resources, political activity and psychological adjustment were examined among
108 Palestinian boys and girls of 11 to 12 years of age. The results showed that
exposure to traumatic events increased psychological adjustment problems, both
directly and via two mediating paths. First, the more traumatic events children
had experienced, the more negatively they perceived their parenting; and the
poorer they perceived parenting, the more they suffered from high neuroticism
and low self-esteem. Second, the more traumatic events children had
experienced, the more political activity they showed; the more active they were,
the more they suffered from psychological adjustment problems.

The perception of good parenting protected children's psychological adjustment

by making them less vulnerable in two ways. First, traumatic events decreased
their intellectual, creative, and cognitive resources, while in a model excluding
perceived parenting a lack of resources caused many psychological adjustment
problems; second, political activity increased psychological adjustment problems
in the same model, but not in the model including perceived parenting.
 “Prison Experiences and Coping Styles among
Palestinian Men,"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj;

Peace and Conflict: Journal of Peace Psychology, 3 (1), 19-36, 1997.

Our aim was to describe different types of prison experience and to analyze their
relations with background and psychological variables. Seventy-nine male
Palestinian ex-prisoners were interviewed about their prison experiences, ways
of coping, personality, and psychological well-being. The results of qualitative
analysis revealed seven different types of prison experience. Only one of these
reflected exclusively negative feelings, characterized by suffering and
disillusionment. The other included relatively rewarding perceptions
characterized as a struggle between strength and weakness, heroic fulfillment,
developmental tasks, a normative stage in a man's life, growth in personal
insight, and a return to religion. Results showed that older men, town residents,
and those exposed to a high level of torture perceived the imprisonment more as
suffering and disillusionment than other men. Ex-prisoners who perceived their
experience as suffering and disillusionment typically coped by using wishful
thinking, avoidance, escape, and distraction. Torture and ill-treatment increased
wishful thinking and self-controlling as coping styles.
 “The Relations between Traumatic Experiences,
Activity, and Cognitive and Emotional Responses
among Palestinian Children”

Samir Qouta, Raija-Leena Punamaki, and Eyad El Sarraj.

International Journal of Psychology, 1995, 30 (3), 289-304

The relations between the level of traumatic experiences, degree of active

participation in the Intifada, and cognitive and emotional responses were studied
among 108 Palestinian children of 11-12 years of age in the Gaza Strip. The
results showed that the more traumatic experiences the children had and the
more they participated in the Intifada, the more concentration, attention and
memory problems they had. Traumatic experiences also increased neuroticism
and risk-taking, and Intifada participation decreased self-esteem. Children's
active participation in the Intifada could not protect children from developing
emotional problems, as was originally assumed. The highest level of neuroticism
was found among active boys who were exposed to many traumatic experiences.
“The Impact of the Peace Treaty on Psychological
Well-Being: A Follow-up Study of Palestinian
Children"

Samir Qouta, Raija-Leena Punamaki, and Eyad El-Sarraj;

Child Abuse & Neglect, 1995, 19 (10), 1197-1208.

This research examined the impact of the Israeli-Palestinian peace treaty and
Palestinian children's perception of it on their self-esteem and neuroticism. We
also studied the relative importance of earlier exposure to traumatic experiences
and psychological resources indicated by children's creativity, intelligence and
political activity in influencing their psychological well-being after the peace
treaty. The sample used was a follow-up group of 64 Palestinian children, 11-12
years of age, living in the Gaza Strip. The results showed that the level of
neuroticism was significantly lower after the peace treaty than before. The
children's earlier exposure to traumatic experiences was still significantly related
to a high neuroticism and low self-esteem after the peace treaty. Acceptance of
the treaty and participating in the subsequent festivities mitigated the negative
impact of the traumatic experiences on their well-being. Increased neuroticism
and low self-esteem were found only among children who refused to accept the
peace treaty and did not participate in the festivities. Creativity and Intifada
activity promoted their post-peace treaty well-being, in terms of psychological
resources. The more creative the children were, the more their neurotic
symptoms decreased because of the treaty and the higher self-esteem they had
after it. The more active the children were during the Intifada, the more their self-
esteem increased because of the treaty.
 "Palestinian Children under Curfew"

Samir Qouta and Eyad El-Sarraj.

Journal of Psychological studies vol. (4), 1-12, 1994.

This study is based on field research work. The purpose of the study was to
estimate the effect of the curfew on children. 547 mothers were asked to record
the behavioral changes of their children during curfew by using the Rutter scale.
Results showed that 66.1% of children began to fight each other and that 54%
were afraid of new things. Significant differences were observed in behavioral
and neurotic symptoms between camp children, resettled children, and town
children.
 “Level of Anxiety in Gaza before and after the
Intifada”

Samir Qouta and Eyad El-Sarraj.

Journal of Psychological studies vol. (1), 1-11, 1993.

This study is based on field research work to estimate the level of anxiety among
the Palestinian people in Gaza Strip, as a measure of the effect of stress. In
comparison with a similar study which was conduced in 1984, significant
differences were observed in the level of anxiety, psychosomatic symptoms and
rigidity and significant rise of anxiety among the citizens of Gaza in comparison
with the camp refugee following the Intifada.