Group Therapy in Treatment
of Post traumatic
Stress Disorder in Palestinian
Children
AA Thabet
Gaza Community Mental Health Programme,
Gaza
Correspondence to:Abdel Aziz Mousa Thabet, Gaza Community
Mental Health priogramme, Gaza P.O Box 1049, Tel 972 7 2865949, Fax 972
7 2824072, .
Abstract
Aim - To
investigate Whether group therapy is effective in as a type of treatment
for PTSD children, the proximity to the event can lead to more symptoms
in children.
, and outcome of traumatic event after group therapy
A sample of 5 children of 12-16 years living in the Jablia
camp in the Gaza strip was selected in the area of the accident. Children
completed the Child Post Traumatic Stress Reaction Index, Impact of Events
Scale, and parents completed Rutter parents scale.
Results - Children reported
high rates of Post traumatic stress reactions , and deviance in behaviour
by parents. This was less after 3 months of group psychotherapy.
Conclusions Group
therap for traumatized children is one of the mesaure which could be used
in small scale therapy and could be applied to large number of traumatized
children.
Keywords: PTSD, group
therapy
Group Therapy in Treatment of
Post traumatic
Stress Disorder in Palestinian
Children
Introduction
Over the last 27 years Palestinian children have been exposed
to a variety of traumatic events including witnessing acts of violence,
beating to themselves or their relative, imprisonment, tear gas, and night
raids (Abu Hein et al., 1993).
According to the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition- Revised (DSM-III-R)(1987), diagnostic criteria
for PTSD include (1) exposure to an extreme stressor outside the range
of usual human experience; (2) re experiencing the traumatic event via
memories, dreams, flashbacks, or distress at exposure to reminders; (3)
persistent avoidance of stimuli associated with the trauma, or numbing
of general responsiveness; and (4) symptoms of increased arousal, such
as sleep disturbance, irritability, difficulty concentrating, hyper vigilance,
and exaggerated startle response.
Howard and Gordon (1972) after the San Fernando earthquake
found that some children still have symptoms one year after the traumatic
event.
Terr(1981) , in her work with psychic trauma of kidnapped
victims, reported about the long-lasting effects of trauma. She reported
a reduction of symptoms in many cases after brief counseling.
Fredrick (1982) in his study found that in three quarters
of the children, symptoms were still evidence 2 years after the traumatizing
event.
Saffer (1986) reported that time limited group therapy was
effective in a group of adolescents who, their friend committed suicide.
Freeman(1991) found that group therapy in a group of people
affected by suicide ineffective in reaching its goal of helping those people.
Dyregrove(1994) reported the efficacy of group therapy in
traumatized children due to loss of their parents.
The traumatic event:
On March 28, 1994, a group of children living in Jabalia
camp (Gaza strip) witnessed the killing of six Fatah Hawks( The army wing
of Palestine Liberation Organization in Gaza strip) by special Israeli
forces. All of the six people were masked and they were shot dead on spot
and all of the children saw their killings, smelt the gunfire, and heard
the gunfire.
Later on they witnessed the carrying of those killed men
in a black bags by Israelis Defense Forces.
Aims of the study:
1) Whether group therapy is effective in as a type of treatment
for PTSD children.
2) The proximity to the event can lead to more symptoms
in children.
3) Outcome of traumatic event after group therapy.
Method
In this study , six preadolescent children between the age
of 12 and 16 years witnessed killing of 6 Fatah Hawks in Jabalia camp on
28th March 1994.
Case 1. A boy age 13
years, a child of family consists of, heard shooting outside his home.
On going outside home he saw people in 2 cars shooting on masked people
in the street. He saw one man chasing another one then he shot him on the
fence of his neighbors home, the boy ran back to his home. He then saw
a crowd of soldiers and blood was every where.
The actual incident involved the killing of six masked people
by the special Israeli force.
Case 2. A boy age 15
years, a child of family consists of 5 brothers and 3 sisters, was standing
in a video shop to borrow a cassette. A masked people were filling their
car in a patrol station and of now where 2 cars stopped and men rushed
out of the cars and started shooting the masked people. He hide inside
the video shop and he witnessed the shooting of the masked people and he
was frightening from the scene of shooting of one of those men in his head
and his brain was gushing outside his skull.
Case 3. A boy age 14
years, a child of family consists of one brother and 5 sisters, watched
masked people distributing leaflets on the near patrol station. A gunfire
started and he hide behind the masked people car. He can not move at that
moment and he saw the killing of the six people and blood was all over
the street and the street was full of special Israeli force and soldiers.
Case 4. A boy age 15
years, a child of a family consists of 3 brothers and 3 sisters, watched
the masked people distributing leaflets. 2 cars came and armed men came
out and started shooting those masked people. He saw one gunman shooting
another one on the patrol station stairs and he saw the man brain and blood
were all over the stairs. He witnessed the shooting of his mother who tried
to protect one of those masked people by her body. He ran from the street
to his house and started to watch through a small holes in their house
wall. He saw soldiers putting the bodies in black bags and they took them.
Case 5. A boy age 15 years,
a child of family consists of 3 brothers and 6 sisters, heard shooting
and ran to his home and through holes in their home wall he saw people
laying on ground and blood around them and soldiers around. Later on he
knew that 6 masked people were shot dead by the special force men.
Case 6 . A boy 15 years
old, a child of family consists of
, heard shooting outside his house and his brother told
him that 6 masked people were killed in the street. When he ran outside
the home he saw the soldiers carrying the bodies of those masked people
in black bags and blood was all over the street.
Methodology
Instruments:
1. Impact of Event Scale
This 15- item scale was developed by Horowitz, Wilner and
Alvarez (1979) to measure the two most characteristic aspects of post-traumatic
psychopathology, namely the strength of unpleasant, intrusive thoughts
and the energy spent in trying to block them out of consciousness. The
intrusive sub-scale of the Impact of Event Scale draws upon the signs and
symptoms of intrusive (invading, disturbing) cognition and affects. The
avoidance sub-scale of the IES draws upon avoidance behaviour, denial or
the blocking of thoughts and image. It is currently the most widely used
instrument in the study of PTSD in adults. It has been used with children
aged 8-16 years ( Yule & Williams, 1990), where it was found that children
who had survived a sea disaster found the questions meaningful and reported
scores as high as those of traumatized adults. The ICES was used to screen
children for PTSD ( Yule & Udwin, 1990).
The ICES was used after the gulf crisis on children in Iraq
(Dyregov & Raundalen, 1991) revealed highly disturbed population of
children who were exceedingly bothered by intrusive thoughts of the war.
This scale was applied on the beginning of group therapy and 2 months after
starting the therapy.
2. Description of Rutter Scale
for completion by parents A (2)
This is a well standardized instrument (Rutter et al, 1970).
The scale consists of thirty-one statements concerning the child's behaviour.
The parent is asked to indicate the frequency of occurrence of the behaviour,
or the degree of its severity, or the extent to which the statement applies
to the child. Each item is cored 0,1, or 2, producing a total score within
the range of 0-62.
The selection of children with emotional or conduct d, tow
largest clinical diagnostic categories (Rutter, 1965), is a two-stage procedure:
1. Children with a total score of 13 or more are designated
as showing some disorder;
2. Of these children, those with an emotional score exceeding
the conduct score are designated as having 'conduct disorder". Children
with equal emotional and conduct subscores remain undifferentiated, although
recent studies indicate that these disorders are more like the conduct
disorders than emotional disorders in terms of the associated impairment
in educational attainments.
The "emotional disorder: subscore is obtained by summing up
the score of items B, G, V, 6 and 15("has stomach-ache or vomiting" " has
tears on arrival at school or refused to go to the building" " does he/she
have any sleeping difficulty?" ; " often worried, worried about many things",
and "tends to be fearful or afraid of new things or new situations").
The "conduct disorder" subscore is obtained by summing the
scores of items III, 3,13, 17, and 18 (" does he/she ever steal things?";
"often destroys own or others" belongings"; "is often disobedient"; " often
tells lies" and bullies other children").
3. Gaza Traumatic Event Checklist
(Abu Hein et al, 1993).
The first checklist was developed by the research department
of the Gaza Community Mental Health Program (G.C.M.H.P)( Appendix). The
checklist consisted of 17 items covering different types of traumatic events
that a Palestinian child may have been exposed to during the occupation
period (tear gas, beating, witnessing the beating, breaking bones, imprisonment,
siblings imprisonment, injury, night raids, humiliation, and detention)
(Abu Hein et al., 1993; Summerfield, 1993). This checklist is completed
by the child himself (age 6-16 years) by "Yes" or "No". The summation of
traumatic events is scored according to the number of the traumatic events.
Less than 5 traumatic events are rated as "few", 5-9 events are rated as
"frequent", and 10 or more as "much".
4. Children Post Traumatic Stress
Reaction Index (PTSD-RI)
(Pynoos et al., 1987)
Fredrick (1985) developed the Post Traumatic Stress Reaction
Index to study the effects of trauma on children. The index is a PTSD scale
developed from DSM-III criteria for the PTSD. This instrument designed
to assess the degree of Posttraumatic symptomatology in children. He reported
that 60% of disaster victims, 100% of children who had been sexually molested,
and 70% of those who had been physically abused, fulfilled PTSD as defined
by DSM-III (APA, 1987).
The CPTSD-RI (Appendix) is a 20-item scale designed to assess
post-traumatic stress reactions of school-age children and adolescents
(6-16 years) following exposure to a broad range of traumatic events. Its
scores by 0, 1, 2, 3, 4 according to presence of symptoms.The scale correlates
at +0.95 with persons diagnosed in clinical settings in hospitals as compared
to those persons diagnosed officially by mental health personnel as having
PTSD.
Previous published empirical comparisons of CPTSD-RI scores
with a diagnosis of PTSD in clinical populations have suggested the following
guidelines: a total score of 12-24 indicates a "mild" level of PTSD reaction;
25-39 a "moderate" level; 40-59 a "severe" level; above 60 a "very severe"
reaction. Inter-rater reliability for this instrument when administered
by a clinician has been reported to be excellent, with a Cohen kappa of
0.87 for inter-item agreement (Pynoos et al, 1987). Table 3.3.4.1.
The PTSDRI was standardized on 750 children and 1,350 adult
cases of stress-laden events and has shown a correlation of .91 with a
positive PTSD diagnosis in children (Fredrick, 1985). More recently, Shannon
et al. (1994) and Lonigan et al. (1994) used the PTSDRI in a study with
more than 5,500 children exposed to Hurricane Hugo. Shannon al. (1994)
reported huge internal consistency values (alpha=.83) for the full instrument
and values ranging from .55 to.86 for symptoms clusters corresponding to
DSM-II-R, Lonigan et al. (1994) provided validity evidence for the PTSDRI
by demonstrating that the presence of PTSD synptomatology assessed by the
PTSDRI was strongly related to self-reported hurricane severity, degree
of home damage, and continued displacement. Similarly , Shaw et al. (1995)
used the instrument in a study of children 2 months after Hurricane Andrew,
estimated coefficient alpha at .75, and the test-retest reliability between
2 and 8 months posthurricane was .59.
This scale was applied on the beginning of group therapy and
3 months after starting the therapy. This scale was translated to Arabic
and validity and reliability testing was done and adapted to Arabic cultures.
Results:
Time (Starting of group therapy)
1- Gaza Trauma Scale:
As shown in Table 1, all children experienced tear gas,
beating, witnessed beating to relatives, humiliation to self and others,
and nightraids.
2. Children Post Traumatic Stress
Reaction Index:
As shown in Table 2, all children scored moderate to severe
degree of post traumatic stress disorder. The higher scores were in Mahmoud
and Ramzy and this could be because they witnessed closely the killing
and Mahmoud saw his mother shooting infront of his eyes.
As it shown in table 3 all of them still shown moderate
post traumatic stress disorder symptoms compared to the start of therapy
in which they showed severe post traumatic stress disorder symptoms.
3- Impact of Events scale
Most of them scored high degree in avoidance and intrusion
symptoms of PTSD.
One month later they showed less intrusion and avoidance
symptoms compared to starting the therapy time.
4- Rutter parents scale
Four of them scored more higher than cut point in Rutter
scale.
Three months later chiltren were scored less in this time,
however it is not a significant one.
Conclusion:
Clinical impression and descriptive data from the group
of traumatized children treated by group treated by group therapy here
seen to support the notion that group therapy is an effective therapy in
traumatized children to some extend and this was apparent in observing
the decline in scoring of PTSD , avoidance and intrusion scores after three
months of therapy.
However ,in looking to Rutter scale there was no much difference
in period of three months and this support other opinions that Rutter scale
is the fact the most of those children experiences. Another reason of no
change of Ruttter scale is the fact the most of those children were chronically
traumatized and some of the neurotic and behaviour problems they have are
due to the previous traumatic experiences.
From our observation during the therapy sessions some of those
children were obsessed with the Special Israeli Forces especially Mohammed.
The therapy session was done in a transition period between
the end of the Israelis occupation to Gaza strip and coming of the Palestinian
police and it was apparent in their drawings the change from pictures full
of killing , and blood to anther shining picture of the Palestinian colored
flags and slogans welcoming the Palestinian police.
Acknowledgment:
Thanks to all those helped my in this research especially
Mr.Jaser Salah who carried with me the group therapy sessions and all workers
in Gaza Community Mental Health Program -Jaballia Branch , without them
this peace of paper will not come in this shape.
References:
Abu Hein, F., Qouta, S., Thabet, A., and El Sarraj, E.(1993).
Trauma and Mental health of children in Gaza. British Medical Journal,
306, 1129-1130.
Dyregrov, A., and Raundalen, M.(1991). The Impact of the Gulf
Crisis on Children in Iraq. Paper presented at Ist International conference
Palestine and Peace Gaza Strip.
Dyregrov, A.(1994) Childhood Bereavement. Consequences and
Therapeutic Approaches. Association of Child Psychology Review &
Newsletter, 16 173-182.
Fredrick, C. J.(1982). Children of disaster. paper read at
the International Association of Child and Adolescent Psychiatry and allied
Professions, Dublin, Ireland.
Freeman, S. (1991). Group Facilitation of the Grieving Process
With Those Bereaved by Suicide. Journal of Counseling & Development,
69, 328-331.
Hor, M., Wilner, N., and Alvapez, W.(1979). Impact of Event
Scale: A Measure of Subjective Stress. Psychosomatic Medicine, 41, 209-218.
Howard, S. H. and Gordon, N. S.(1972). Mental Health intervention
in major disaster. NIMH research grant. MH 21649-09. Child Guidance Clinic.
San Fernando. Calif.
Nadir, K., Pynoos, R., Fairbanks, L., and Frederick, C.(1990).
Childrens PTSD Reaction One Year After a Sniper Attack at Their School.
and Behaviour. Longman: London.
Nader, K., Fairbanks, L., Al-Ajeel, M., and 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.
Pynoos, R., Frederick, C., and Nader, K.(1987). Life threat
and post traumatic stress in school children. Archives of General Psychiatry,
44, 1057-1063.
Rutter, M., Tizard, J., and Whitmore, K.(1970). Education,
Health and Behaviour. Longman: London.
Rutter, M., Graham, P.(1967). A childrens behaviour questionnaire
for completion by teachers: preliminary findings. Journal of Child Psychology
and Psychiatry, 8, 1-11.
Yule, W., and Williams, R.(1990). Posstress reactions in children.
Journal
of Traumatic Stress, 3(2),279-295.
Yule, W., Udwin, O., and Murdoch. (1990). The Jupitor sinking:
Effects on childrens fears, depression to the first European Conference
on Traumatic Stress Research, Lincoln, August.
Table 1
Children exposed to different types
of trauma
|
Types of traumatic event
|
No
|
%
|
1.Tear Gas
2.Beating
3.Witnessing beating of relatives
4. Breaking bones
5. Breaking bones of relatives
6. Imprisonment
7. Imprisonment of close relatives
8. Injury
9. Night raids
10. Humiliation
11. Family members humiliation
12. Detention
|
6
6
6
0
4
0
4
1
6
6
6
4
|
100% 100%
100%
0.00
66.7%
0.00
66.7%
16.7%
100%
100%
100%
66.7%
|
Table
2:
Differences in CPTSD-RI scoring
applied to 6 traumatized Palestinian children three
months after trauma and group therapy
|
|
Children PTS Reaction Index
|
|
|
Time 1
|
Time 2
|
|
Mahmoud
Ramzy
Khalid
Ahmad
Mohammed
Yousif
|
56
51
49
47
47
44
|
30
34
35
31
39
44
|
Table 3:
Differences in Impact of Events
Scale scoring applied to 6 traumatized Palestinian children three months
after trauma and group therapy
|
Intrusion
|
Avoidance
|
Name
|
|
Time 2
|
Time 1
|
Time 2
|
Time 1
|
|
|
14
20
17
12
31
12
|
30
31
24
27
27
22
|
6
10
17
11
22
17
|
27
19
29
25
31
27
|
Mahmoud
Ramzy
Khalid
Ahmad
Mohammed
Yousif
|
Table 4:
Differences in caseness rated by
Rutter Parents scale applied to 6 traumatized Palestinian children three
months after trauma and group therapy
|
|
Time 1
|
Time 2
|
|
Mahmoud
|
22
|
15
|
|
Ramzy
|
25
|
17
|
|
Khalid
|
21
|
22
|
|
Ahmad
|
12
|
5
|
|
Mohammed
|
21
|
21
|
|
Yousif
|
7
|
16
|
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