Specific and non-specific post -traumatic stress disorder symptoms in Palestinian children
Abdel Aziz Mousa Thabet and Eyad El Sarraj - 1992

Over the past 25 years, the children of the Occupied Territories in the Gaza Strip and West Bank have confronted a variety of traumatic events, including witnessing  act of violence to friends, relatives, experiencing physical trauma themselves, imprisonment, and shootings.  Trauma in  the Gaza Strip has been continuous for individual cases; and in families, specific trauma has often been repeated.  During the  Intifada (December 1987 to present), the trauma inflicted on the population has become more severe and frequent.

Children's health and behaviour following exposure to environments of war, armed conflict, military oppression, and occupation is characterized by a variety of symptoms. The most  common symptoms include, nervousness, social withdrawal, anxiety, fearfulness, trembling, crying, headaches, and other somatic complaints, regression of bowel habits, and a drop in school performance( Bodwan, 1941; Freud & Burlingham, 1941; Frazer, 1974 ; Terr, 1979; Punamaki, 1987; Pynoos et al, 1986; Allodi, 1980, 1988; Hjerne, 1990; Baker, 1991).
 Other factors like personality, concurrent psychiatric disorders, age and gender, social, family, and cultural could be risk or protective factors. The outcome of trauma is modulated or buffeted by family and the social support system to the degree that overt pathological effects are not obvious in follow up studies ( Allodi, 1988).
 Cultural factors can influence the children response to traumatic events. Krupinski (1986) in study of  the  South Asian refugee children  who setteled in Australia found that somatoform symptoms (according to Rutter scale) were more frequent than in  the native Australian children control group.

Methodology
This study sought to explain the type and frequency of traumatic event in children and the symptomatology of Post-Traumatic Stress Disorder, specific and nonspecific, cultural factors affecting response to trauma.

The sample of the study involved all children (N: 70) treated at Gaza Community Mental Health Programme (G.C.M.H.P), diagnosed as a case of Post traumatic stress disorder according to the DSM-III-R. Data  was retrospectively taken from the records of 70 cases treated at our clinics at Gaza, Khan Younis, and Jabalia. They included assessment interviews and progress notes written by psychologists and psychiatrists at the centre.
The sample included 46  boys and 24 girls. The mean age was 12.9 years. 16 cases (22.85%) were 5-9 years old, 25 cases (35.69%) were 10-14 years old, and 28 cases (40%) were 15-18 years old (Table 1). 22 cases (41.42%) were from Gaza city and surrounding camps; 23 cases (33.86%) were from the Middle area (mostly camps); 16 cases (22.86%) were from North Area; and 9 cases (12.86%) were from the South Area including the refugee camps (Table 2). 4 cases (5.72 %) were illiterate; 20 cases (34.57 %) were in Kindergarten; 19 cases (27.14%) were in preliminary school; 12 cases (17.14%) were in primary school; and 12 cases  (20 %) were in secondary school (Table 3).

Table 1
Age group in 70 Children Treated at G.C.M.H.P/1990-1992

Sex , Age by Years
Male
Female
No.
%
No.
%
5 -9 Y
11
15.71
5
7.14
10-14 Y
13
18.57
12
17.14
15-18 Y
21
30.00
7
10.00
Total
46
65.71
24
34.29
 
Table 2
Place of residence of 70 children treated at G.C.M..H.P/1990-1992
Area
Male
Female
No.
%
No.
%
North Area
10
14.29
6
8.57
Gaza Area
18
25.71
4
5.71
Mid Area
15
21.43
8
11.43
South Area
3
4.29
6
8.57
Total
46
65.71
24
34.29
 
 
Table 3
Level of education in 70 children treated at G.C.M..H.P/1990-1992
Education
Male
Female
No.
%
No.
%
Illiterate
2
2.8
2
2.86
Kindergarten
9
12.86
11
15.71
Elementary
14
20
5
7.14
Primary
11
15.71
1
1.43
Secondary School
9
12.86
5
7.14
Total
46
65.71
24
34.29
 
Results
The most common traumatic event was witnessing violence against relatives or non relatives 52 cases (74.29%), beatings to self 31 cases (44.29%), imprisonment 15 cases (21.44%),injury by shooting  9 cases (12.86%), trauma due to inhalation of tear gas 4 cases (5.72%), and rape (female 1) (1.43%)(Table 4). In our sample, 32 cases experienced more than one trauma at the same time. The most frequent symptoms reported in the PTSD list were recurrent memories, nightmares, fears, nervousness, loss of appetite, withdrawal , headaches, body pain, stomach pain, aggressive behaviour, low school performance, avoidance behaviour, weeping, and conversion fits (Table 5).

Table 4
Trauma by sex in children treated at G.C.M..H.P (No:70) 1990-1992

Types of Trauma
Male (N:46)
Female (N:24)
No.
%
No.
%
1. Witnessing Violence
        
Close Relative
26
37.14
18
25.71
Non Relative
6
8.57
2
2.86
2. Beating
        
Head
5
7.14
4
5.71
Trunk
1
1.43
1
1.43
Multiple
15
21.43
5
7.14
3. Injured by shooting
        
Head
2
2.86
1
1.43
Limbs
3
4.29
0
0
Body and Multiple
8
11.43
1
1.43
4. Prison
8
11.43
1
1.43
5. Tear Gas
        
Open Space
1
37.14
1
1.43
Closed Space
1
1.43
1
1.43
6. Rape
0
0
1
1.43
 
 
Table 5
Specific and Nonspecific Post-Traumatic Stress Disorder
Symptoms in Children Treated at G.C.M..H.P (No:70) 1990-1992
Types of Trauma
Male (N:46)
Female (N:24)
No.
%
No.
%
1. Specific Symptoms
        
1. Re-experienncing 
        
Nighhtmares
37
52.86
22
31.43
Recurrent memmories
40
57.14
17
24.29
Triggered reaction
18
25.71
8
11.43
2. Hyperarausal
        
Sleep distubance
33
47.14
16
22..86
Suspiciousness
3
4.29
1
1.43
Easily startled
9
12.86
10
14.29
Irritability
33
47.4
16
22.86
3. Denial / avoidance
        
Avoidance behaviour
24
34.29
17
24.29
School phobia
5
7..14
0
0
4. Numbing and depression
        
Withdrawal
30
42.86
18
25.71
Weeping
22
31.43
16
22.86
Pessimism
16
22.86
6
8.57
Low school performance
24
34.29
17
24.29
Loss of appetite
30
42.86
16
22.86
2. Non Specific Symptoms
        
1. Psychosomstic
        
Headaches
30
42.86
15
21.43
Stomach pains
2
2.86
3
4.29
Body pains
14
20.00
11
15..71
2. Somatoform
        
Conversion fits
7
10.00
6
8.57
3. Miscellanneous
        
Enuresis
12
17.14
6
8.57
Encopresis
1
1.43
1
1.43
Stuttering
4
5.71
1
1.43
Tics
3
4.29
0
0
Disobeddience
7
10.00
2
2.86

Conclusion
This study showed that the most common traumatic events for the  children attending our clinic were witnessing acts of violence against relatives or non relatives, beatings to themselves, and being injured by shooting. There were more boys than girls and this indicator as in other studies in which boys are more vulnerable to develop PTSD symptoms than girl (Newman, 1976). The most common cases were from Gaza, which included the Beach camp and other crowded areas of Gaza. In the camps area the bad socio-economic status of children living at that area is another factor in making our children more vulnerable to trauma.

Our results  showed that post-traumatic stress disorder symptoms can change according to cultural background. This was supported by findings of that 12 cases had developed conversion disorder symptoms in the form of conversion fits.  It has been observed that persons in Eastern culture people react to stressful conditions by showing somatoform symptoms which include motor, sensory, and dissociative symptoms (Mollica, R. 1987).

The psychiatric symptoms of post-traumatic stress disorder in children can be different even if the trauma is the same. However, differences in the culture in which the trauma occurred can yield symptoms which are not common in other cultures.

* Acknowledgement.  Thanks to all those helped us in this research, especially , Dr. F. Allodi, Mrs. R. Saba, and all of the mental health team members working at our programme.

References:
1. Allodi, F.(1980). The psychiatric effects in children and families of victims of political repression andtorture.-Danish Medical Bulletin, 27, 229-232.

2. Allodi, F.(1988). The children of victims of political  persecution and torture: A psychological study of a  Latin American refugee community. Paper presented at the 141st Annual Meeting of the American Psychiatric  Association, Montreal, Canada, 7-13 May.

2. American Psychiatric Association.(1987). DSM-III-R. Diagnostic  and statistical manual of mental disorders (3rd edn, revised). American Psychiatric Association. Washington, DC:

3. Baker, A. M.(1991). Psychological responses of Palestinian children to environmental stress associated with military  occupation. Journal of Refugee Studies, 4 (3), 237-247.

5. Bodwan, F.(1941). War conditions and the mental health of the  child. British Medical Journal. October, 486-488.

6. Frazer, M.(1974). Children in conflict. Harmondsworth:Penguin  Books.

7. Furman, E.(1986). On trauma: When is the death of a parent traumatic. Psychoanalytic Study of the child, 41.191-208.

8. Freud, A. & Burlingham, D.(1941). Infants without families.  Reports on the hampstead nurseries. The writings of Anna Freud. Vol II. International Universities  Press.Inc. New York.

9. Krupnick, J. L. and Horowitz, M. J .(1980). Victims of  violence: Psychological
responses and treatment applications. Evaluation and change (Special issue) 42-46.

10. Krupinski, J.(1986). Summary. In J Krupinsky, G burrows  (Eds), The  price
of freedom . Young Indochinese  refugees in Australia (pp-232-243). Pergamon.
Sydney, Australia.

11. Hjerne, A. (1991). The health of newly resettled refugee  children from Chile and the Middle east.  Stockholm:  Dep.of paediatrics, Huddinge University Hospital.

12. Mollica, R. F,Wyshak, W. and Lavelle, J.(1987). The  psychosocial impact of war truama and torture on Southeast Asian refugees. American Journal of psychiatry, 144, 1567-1572.

13. Newman, C. J.(1976). Children of disaster. Clinical observation at Buffalo
Creek. American Journal of Psychiatry, 133, 306-312.

14. Punamaki, R, L.(1987). Psychological stress responses of Palestinian mothers
and their children in conditions of military occupation and political violence. The
Quarterly  newsletter of the Laboratory of Comparative Human Cognition, 99, 76-81.

15. Pynoos, R. S. and Spencer, E.(1986). Witness to violence: The child interview.
Journal of the American Academy of Child  Psychiatry, 25, 3:306-319.

16. Terr, L. C.(1979). Children in Chowchilla : A study of psychic terror. The psychoanalytic study of the child  34, 547-623.

Thabet , A. A, MD.- Gaza Community Mental Health Programme
El Sarraj , E. R, MD. Gaza Community Mental Health Programme

 CONTACT   HOME
GCMHP, Gaza Palestine P.O. Box 1049 Tel: + 972 7 2865949  Fax: + 972 7 2824072