Child and Adolescent Mental Health Volume 12, No. 1, 2007, pp. 27–31
doi: 10.1111/j.1475-3588.2006.00416.x
Psychological Symptomatology Among
Palestinian Adolescents Living with Political
Violence
Alean Al-Krenawi,1 Rachel Lev-Wiesel2 & Mahmud, A. Sehwail3
1
Spitzer Dept. of Social Work, Ben-Gurion University of the Negev, Beer Sheva 84105, Israel. E-mail: [email protected]
School of Social Work, University of Haifa, Haifa 31905, Israel. E-mail: [email protected]
3
The Treatment and Rehabilitation Center for Victims of Torture, PO Box 468, Ramallah, Palestine
2
Background: The study examined the impact of the level of exposure to political violence on the psychological
symptomatology of Palestinian adolescents in the West Bank, an area affected by the ongoing political
violence between Israel and the Palestinian Authority. Method: A random sample of 1775 participants (54.1%
males, 45.9% females) between the ages of 12–18 was administered a self-report questionnaire consisting of
three measures: demographic variables, domestic violence, political violence events and psychological symptomatology (BSI). Results: Results indicated that the average psychological symptomatology was higher
among those who were exposed to political violence events compared to those who were not; the level of
hostility was significantly higher in those who were exposed to each of the political violence events. However,
the factors that contributed most to psychological symptomatology were parental violence toward children
and violence among siblings.
Keywords: Political violence; domestic violence; psychological symptomatology; Palestinians adolescents
Introduction
As a result of the Second Intifada (Palestinian Uprising
2000–2004), curfews have been a regular occurrence
and geographic mobility has been restricted, sometimes
preventing access to medical treatment, employment
and provisions. Schools and universities are often
spontaneously closed and re-opened, homes are unexpectedly searched by the army, shootings and urban
stone throwing are frequent sights. According to the
Ministry of Health in Gaza (cited in Thabet & Vostanis,
2005), the total number of casualties numbered
36,299, including 1151 deaths in Gaza and 1441
deaths in the West Bank. The Intifada also seriously
debilitated the economy; the unemployment rate has
increased from 23 to 45% and poverty rates rose from
25 to 60% (The Atlantic, 2003; United Nations, Office of
the United Nations Special Coordinator, 2002; World
Bank, 2003). In addition, Srour (2005) points out that
since the beginning of the Second Intifada approximately 2.5 Palestinians have been killed each day, with
23% (827) of them under the age of 18. Moreover, 3409
elementary school age children were injured and more
than 500 children arrested during this period for Intifada related activities.
Many young adult Palestinians were involved directly
or indirectly in the actual fighting while others witnessed the events. Thabet and Vostanis (2005) reported
in a study of 286 Palestinians aged 9–18 years that 67%
suffered from posttraumatic stress reactions. Other
findings revealed that 73% of the Palestinians felt
insecure (Giacaman et al., 2004). This insecurity was
reinforced by increased rates of domestic violence;
11.3% of the Palestinians reported that they were victims of household violence, a rate double than that of
1996. In general, 29.5% of the population reported
being a target of an aggressive act or assault (Al-Ashhab, 2005). Moreover, a Palestinian researcher found
that children exposed to political violence may display
symptoms indicative of a sense of a loss of control such
as bed-wetting, behavioral problems, mutism, or
separation anxiety, including refusal to attend school.
In addition, certain emotions such as fear and rage may
be transferred, thereby precipitating violence at home
or in the school setting. Such reactions may involve
indirect aggression to show others Ôhow it feels to be
frightenedÕ or, alternatively, may cause increased
depression and withdrawal (Srour, 2005).
The current study investigated the psychological
well-being of Palestinian adolescents in the West Bank,
who live with the ongoing political violence between Israel and the Palestinian Authority.1 The results presented are part of a longitudinal survey conducted by
the Treatment and Rehabilitation Center for Victims of
Torture (TRC) in the West Bank (2005). More specifically, this study examined the impact of the level of
exposure to political violence on the psychological
symptomatology in Palestinian adolescents.
There is a general recognition that children are at risk
when they are exposed to either direct political violence
1
Since this study focuses on the impact of exposure to political
violence on the psychological well-being of Palestinians adolescents, the implications of the bloodshed on Israeli society
will not be discussed in this report.
Ó 2006 Association for Child and Adolescent Mental Health.
Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA
28
Rachel Lev-Wiesel et al.
(such as injury, arrest or torture), or subject to indirect
political violence such as loss of a family member or
witnessing the humiliation or injury of a family member
(Kinzie, Boehnlein, & Sack, 1998; Cairns & Lewis,
1999; Machel et al., 2001; Punamaeki, Quota, & ElSarraj, 2001; Reilly, 2002). Studies indicate that political trauma causes a variety of effects in three related
areas of young people’s lives: everyday aspects of life,
social identity, and mental health (Al Krenawi, Graham,
& Sehwail, 2004; Muldoon, 2004). The effects of political violence include, but are not limited to, psychological symptoms of distress such as: posttraumatic
stress disorder, numbness, depression, anxiety, emotional disorders, regressive behaviours (Jensen &
Shaw, 1993), changed attitudes and beliefs (Terr,
1983), and diminished hope for the future (Cairns,
1996).
Children exposed to political violence may present
with similar difficulties to those who are direct and indirect victims of domestic violence (Sameroff, 2000).
Furthermore, numerous studies indicate that exposure
to domestic violence is a nonspecific risk factor that
may lead to negative outcomes in the short- and longterm (e.g. Wolfe et al., 2003), over and above other
coexisting factors (e.g. Coyne, Barrett, & Duffy, 2000).
Therefore, in addition to examining the level of exposure
to political violence events, this study investigated the
level of exposure to domestic violence in the lives of
Palestinian adolescents.
Based on the above and on the findings of a recent
study that investigated the mental health of Palestinian
adolescents and adults, revealing that both childhood
maltreatment and military violence in adults were associated with high levels of mental health symptoms
(Punamaki et al, 2005), we hypothesized the following:
(a) the level of exposure to political violence would be
associated with the severity of psychological symptomatology; and (b) exposure to domestic violence in
addition to political violence would exaggerate the
severity of adolescent psychological symptomatology.
The West-Bank
The West Bank is an area of land between Israel and
Jordan, totalling 5860 square kilometres. With a population of over 3 million, and nearly half of the population under the age of 14, growth rates are high. The
West Bank and Gaza together constitute Palestine,
which is administered by the Palestinian Authority (PA).
Most of the population is Muslim, and common Palestinian values include rootedness to the land, strong
family bonds, social identity from family and community, and a holistic outlook on life (Al-Krenawi & Graham, 2003). Palestinians refer to the establishment of
the State of Israel in1948 as a disaster (Al-Nakhba),
creating a crisis in all aspects of Palestinian life, a crisis
that persists to the present time (Al-Krenawi & Graham,
2005, Srour, 2005). The 1967 capture of the West Bank
and Gaza initiated a period of political occupation that
further restricted PalestiniansÕ political autonomy. As a
result of the ongoing conflict with Israel, Palestinians
have been under military curfew, and have experienced
overwhelming economic loss. The First Intifada or
Uprising, which began in 1987 and continued through
the early 1990s, had deep consequences for all aspects
of Palestinian life. The Second Intifada, beginning in
September 2000 and ending in 2004, has been equally
intense and destructive. In 2005, more than 60% of
Palestinian households lived below the national poverty
line, compared to 20% in 1998. World Food Program
statistics of 2004 indicate that 37% of the Palestinian
population are food-insecure and do not receive adequate food to meet minimum nutritional requirements.
With such a young population, it is timely to analyse the
social and psychological consequences of the ongoing
political violence in the lives of Palestinian youth. Insight into this phenomenon could have significant
implications for the region’s future.
Method
Participants
The sample was derived from major cities, refugee
camps and villages, randomly selected from a computer
database of the Palestinian Central Bureau of Statistics
by computer software. The sample consisted of male
and female adolescents aged 12–18.5 (M ¼ 15.56,
SD ¼ 1.22) attending school. We assured that all the
regions in the West Bank had the same probability of
being included in the final sample. The schools were
randomly chosen, and from each age group a sample
was randomly selected. From the initial set of 2328
respondents, the final sample consisted of 1775 adolescents (54.1% males, 45.9% females), exclusively
including participants residing in major cities. Those
living in villages and refugee camps were excluded because the most serious violence took place in the larger
cities. Most of the teenagers lived with both their parents (88.7%) while 6.6% were orphaned of their fathers
and 1.2% of their mothers. The average number of
children at home was 6.92 (SD ¼ 3.11).
Measures
Specially trained students from West Bank universities
administered the questionnaires. Because of cultural
norms, these interviewers were both male and female.
They were present while the participants completed the
questionnaires, in order to answer questions and to
clarify questions. The interviewers provided the participants with a detailed explanation about the purposes
of the study and assured them that they can choose to
terminate their participation at any time.
The self-report questionnaire consisted of the following measures: demographic variables such as the
socio-economic status of the adolescent’s family;
Domestic Violence Scale; Political Violent Events Scale
(the latter two measures were prepared by the research
teams based on focus groups adapted to cultural norms
and specific situations); and the Brief Symptom Inventory (BSI) that measures psychiatric symptomatology
(Derogatis & Melisavados, 1983; Derogatis & Spencer,
1982).
Domestic Violence Scale, developed by the authors,
measures two-dimensional verbal and physical violence
within the family: violence between parents and children or between siblings (9 items) and spousal violent
relationships (4 items). Respondents were asked to rate
the level of occurrence ranging from ÔAll the timeÕ (5) to
ÔNeverÕ (1). Cronbach’s alpha reliability coefficient was
found to be .87 (.85, .92 respectively).
Psychological Symptomatology among Palestinian Adolescents
Political Violent Events Scale, developed by the authors, measures the level of subjective severity of
experiencing different political events activated by Israel. Respondents were asked first to indicate (Yes or
No) whether they experienced any of the following
events: physical or verbal abuse at a military checkpoint; the arrest of themselves or a family member;
being subject to long curfew periods, injury by military
personnel, the violence related death of a relative,
property damage or loss during military house searching. If the answer was yes, they were asked to rate the
level of severity ranged from Ôno impactÕ (1) to Ôserious
impactÕ (5). Cronbach’s+ alpha reliability coefficient was
found to be .92.
The Brief Symptom Inventory (BSI) is a shortened
version of the Hopkins Symptom Checklist (H-SCL-90).
It includes 53 items that elicit perception of symptoms
during the last month. The nine dimensions of the BSI
are: somatisation, interpersonal sensitivity, obsessioncompulsion, depression, anxiety, hostility, phobic
anxiety, paranoid ideation and psychotic symptoms. In
addition, the scale provides a General Severity Index
(GSI), a Positive Symptom Index (PSDI), and a Positive
Symptoms Total (PST). The scale has been used to assess mental health of Soviet, American and Israeli
adolescents in several studies (Canetti, Shalev, KaplanDe-Nour, 1994; Slonim-Nevo & Sheraga, 1997). The
internal consistency of the nine sub-scales is adequate
(Cronbach’s alpha ¼ .71–.81) and an adequate level of
reliability has been found to exist by test-retest analysis
(r ¼ .60–.90). Cronbach’s alpha reliability coefficient in
the current study was found to be 0.94. The BSI was
translated into Arabic, and back translated by a professional translator, fluent in both Arabic and English,
and then it was independently translated back into
English to ensure the accuracy of translation. It should
be noted that the BSI has been successfully utilised in
previous research amongst Arab youth in the Middle
East (Al-Krenawi, Graham, & Slonim-Nevo, 2002).
Results
Correlation analysis (Pearson) between the study variables showed negative correlations between family
socio-economic status and domestic violence (r ¼ ).14,
p < .01), spousal violence (r ¼ ).13, p < .01), and political violence (r ¼ ).06, p < .01), and the BSI mean
score (r ¼ ).15, p < .01). Positive correlations were
found between the BSI mean score and domestic
violence (r ¼ .46, p < .01), spousal violence (r ¼ .29,
p < .01), and political violence (r ¼ .14, p < .01).
Frequency analysis of experiencing each of the political violence events indicated the following: 50% of the
participants reported that either themselves or one of
their family members had been arrested by Israeli military forces, 80.1% experienced living under frequent
curfews, 35.7% experienced degradation or abuse at
military checkpoints, 12.1% were injured as a result of
shooting, 39.8% experienced the death of a close family
member, 26.2% experienced property damage, and
41.3% experienced military house searching.
Multivariate analyses (MANOVA) were conducted
using exposure to psychological symptomatology (BSI)
as the dependent variable and the participant’s subjective evaluation of severity of the events as the inde-
29
pendent variable. Means, SD, and univariate F scores
for the psychological symptomatology of those who were
exposed to political violence events, compared to those
who were not, are shown in Table 1. The findings revealed significant differences between the two groups in
all political events except two, having been shot at, and
the death of a relative. In relation to the symptoms
themselves, results show that exposure to all the events
contributed significantly to the level of hostility (arrest
F ¼ 16.33, p < .001; abused in a checkpoint F ¼ 17.34,
p < .001; shot F ¼ 13.58, p < .001; death of a relative
F ¼ 15.48, p < .001; curfew F ¼ 12.52, p < .001; property damage F ¼ 16.18, p < .001; house searching F ¼
28.98, p < .001). Other symptoms were affected differently by different types of events.
Regression analysis indicates that 21.3% of the
variance of psychological symptomatology can be explained by the following orderly presented variables:
domestic violence (b ¼ .42, p < .001), exposure to political violence events (b ¼ .10, p < .001), and the family
socio-economic status (b ¼ .07, p < .01).
Discussion
The study sought to examine the impact of exposure to
political violence on the mental health of Palestinian
adolescents. Findings revealed that although domestic
violence (particularly violence between parents and
children and between siblings) was found to contribute
the most to psychological symptomatology, the exposure to political violence events also contributed to
heightened psychiatric symptomatology. The findings
indicated that hostility was a common symptom that
was instigated by exposure to each of the political
violence events. This symptom, or rather the anger that
might be manifested by it, is often overlooked within the
posttraumatic response frame. The anger of youth that
witness or are directly involved in political violence
might add to the Palestinian intercommunity tension
because of their actual inferiority against the Israeli
army, thereby having implication on reconciliation between Israelis and Palestinians. It can be presumed that
the longer the occupation continues, the higher will be
the level of hostility. Since the adolescents of today are
Ôtomorrow’s playersÕ, then a heightened level of hostility
among Palestinian adolescents today will lower their
emotional ability to establish trust toward Israelis in the
future, thereby inhibiting true reconciliation and peace
building.
However, it should be noted that despite the high
level of exposure to traumatic events, the symptomatology associated with political violence is relatively low.
This finding could be a manifestation of collective resilience or what Warner, Baro and Eigenberg (2004)
described as normal behaviour in an abnormal situation. Palestinian children/adolescents who were born
and lived under the political violence do not know life
free of war. These children/adolescents were born
during the First Intifada and are coming of age during
the Second Intifada. This finding seems to be in line
with that of Rudenberg, Jansen and Fridjhon (2001),
who analysed the drawings of children aged 8–12 years
as a method of understanding the effects of living and
coping with ongoing civic unrest in Belfast. They found
that boys from Belfast had higher levels of anger and
30
Rachel Lev-Wiesel et al.
Table 1. Means, standard deviations and F scores of the BSI comparing adolescents who were exposed to each of the political violence
events with those who were not
Political event
You or one of your family members have been arrested
Mean
SD
N
You were abused in a military checkpoint
Mean
SD
N
You have been injured or shot by the Israeli army
Mean
SD
N
A relative of yours died or was injured by the Israeli army
Mean
SD
N
Your house or property was damaged by the Israeli military forces
Mean
SD
N
You were under curfew or forbidden to leave your house or city
Mean
SD
N
Your home was searched by the soldiers
Mean
SD
N
Yes
No
33.43
10.65
659
Yes
33.53
10.26
620
Yes
32.55
11.01
214
Yes
32.65
10.56
703
Yes
33.73
10.48
464
Yes
34.57
10.27
372
Yes
33.61
10.34
726
32.00
10.82
1103
No
31.98
10.92
1116
No
32.49
10.71
1559
No
32.35
10.88
1065
No
32.07
10.80
1305
No
31.97
10.79
1400
No
31.75
10.96
1034
F(1,1760)
7.35*
F (1,1734)
8.36*
F (1,1771)
0.00
F(1,1766)
0.32
F(1,1767)
8.18*
F(1,1770)
17.44**
F(1,1758)
12.84**
*p < 01; **p < 001.
aggression, yet employed more use of coping mechanisms such as denial and social support and therefore
had greater resilience.
The fact that exposure to gunfire was not found to
significantly contribute to the level of distress was
surprising. Yet, we hypothesize that Palestinian society’s acknowledgement of those killed as a result of the
fight to Ôfree the landÕ as martyrs, and the resultant
providing of emotional and instrumental support for the
affected families, somehow balances the impact of these
adverse events.
It is not surprising that domestic violence, especially
violence between parents and children and between
siblings, was found to reduce children’s mental health.
This finding is consistent with numerous studies indicating that maltreated children suffer from more
behavioural and emotional difficulties than children of
supportive parents (Edmond et al., 2002; Downs &
Rindels, 2004).
To conclude, we hope that the findings delineated
here will heighten the awareness of school teachers,
mental health practitioners, and policy makers about
the negative effects of the ongoing Israeli-Palestinian
political violence on the psychological well-being of Palestinian children and adolescents.
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