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2008, 32 (4), 322–336
© 2008 The International Society for the
Study of Behavioural Development
http://www.sagepublications.com
DOI: 10.1177/0165025408090974
The well being of children living in chronic war zones:
The Palestinian–Israeli case
Abraham Sagi-Schwartz
University of Haifa, Israel
The paper presents a comprehensive review and integration of available studies on the effects of
severe traumatic experiences on children, especially in the context of short and enduring exposure
to harsh events and adversities, as they relate to children who live in violent war zones, in particular
in Israel and the Palestinian territories. The review focuses on the role of risk and protective factors
in determining the debilitating and damaging effects as well as resiliencies of short term and chronic
catastrophic experiences on the future well being of children and emerging adults.
Keywords: children; wars; Palestinian; Israeli; resiliency; vulnerability
As this paper is being written – as at the time it will be
published and available to readers – wars and political violence
in many parts of the world continue to cause suffering,
destruction, and loss of life and leave their scars on those who
survive them. In one of her articles about children of wars,
Jagodić (2000), a Croatian psychologist, asked: “Is war a good
or a bad thing?” The answer is rather simple; yes it is bad,
indeed very bad for all. However, one major question arises,
especially in the context of intractable conflicts: Does one
necessarily become severely damaged when exposed to
intractable conflicts and violence? While historians study the
dynamics of wars past and political scientists their causes,
developmental psychologists can serve the cause of peace by
examining their effects on children and their families and by
analyzing conditions that lead to greater risk as opposed to
those that may protect children of violence adversity. We need
to understand at a deeper level the development and nature of
the state of mind and forms of behaviors of those children,
adolescents, and subsequently emerging adults, who are
victims of chronic exposure to political violence and unending
“social toxicity”. More appropriate approaches, policies, and
interventions can then be established that take into account the
mental scars that might be left with exposed children (Terr,
1992) as well as their resilience, adjustment, and coping skills.
Various related aspects of human development, the study of
trauma, and the potential effects of exposure to continued war
conditions on children and their families are presented here,
along with a number of questions and hypotheses that are
explored. The work consists of an extensive review, evaluation
and integration of existing published and unpublished sources.
Such a review may serve as a basis for drawing hypotheses and
tentative conclusions about future directions for research,
prevention, and intervention. This paper will accordingly draw
from the area of traumatic stress research with a special focus
on the meaning of living under war conditions (versus other
stress related conditions such as child maltreatment within the
family), particularly that which analyzes the quality of the
This work is part of a larger project that was carried out during the
author’s residence as a Jennings Randolph Senior Fellow at the United
States Institute of Peace (USIP). The generous support of USIP is
deeply appreciated.
mental health infrastructures in both Israeli and Palestinian
societies. With this goal in mind we move now to a comprehensive review of studies examining traumatic stress in war
zones.
Traumatic stress in war zones
Overview
The following analysis consists of a comprehensive review and
integration of available published and (some) unpublished
studies on the effects of severe traumatic experiences on
children’s state of mind and functioning, especially in the
context of short and enduring exposure to harsh events and
adversities, as they relate to children who live in violent war
zones throughout the world as well as in Israel and the Palestinian territories. The review focuses on the role of risk and
protective factors in determining the debilitating and
damaging effects as well as resiliencies of short term and
chronic catastrophic experiences on the future well being of
children and emerging adults.
We will explore the conditions that may leave profound traumatic and permanent “psychic scars” (Terr, 1992), as these
may attract children to violent groups as a mean for dealing
with disputes and conflict. Consequently, the children themselves may threat our society, in light of their likelihood to
exhibit heightened aggression, violence, and revenge seeking
(Garbarino & Kostelny, 1993a). We explore to what degree
growing under chronic danger, without adequate social
support systems, may be developmentally harmful to children
so that they are likely to perceive themselves as unworthy, the
adults around them as non-trustful, and the various social
institutions as threatening and unsafe (Garbarino & Kostelny,
1993a). The conditions under which children might become
outstandingly resilient in their capacity to tolerate even very
overwhelming adversities are examined as well.
Correspondence should be sent to Abraham Sagi-Schwartz, Center
for the Study of Child Development, University of Haifa, 6035 Rabin
Building, Haifa 31905, Israel; e-mail: [email protected]
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What is trauma?
Trauma is defined as a painful emotional experience, or shock,
often producing a lasting effect. There are various aspects of
trauma with a wide scope and many forms which result from
a broad range of occurrences including life-threatening situations stemming from natural or man-made disasters and
catastrophes; severe physical injury; torture; traumatic loss of
family members, friends and other significant attachment
figures; loss of one’s community or social environment;
physical/sexual abuse or assault; experiencing or witnessing
family or community violence; and exposure to war, terrorism,
kidnapping, violence, and political oppression. Children then
may become rather vulnerable, especially when they become
witnesses to violence (American Psychiatric Association,
1994).
Short term/acute versus long term/chronic exposure to
trauma
A distinction should be made between short-term versus longterm effects. Some research suggests that negative effects in
children and youth exposed to political violence tend to decline
and disappear over time – even in war zones that induced
extremely high levels of violence and hostility, such as Bosnia,
Cambodia, and South Africa. Garbarino & Kostelny (1993a,
1993b) propose that non chronic short-term exposure to single
events may often result in natural adaptive reactions of fear and
anxiety. On the other hand, the long lasting status of chronic
exposure to trauma may involve PTSD symptoms, namely
severe psychological and psychiatric reactions. According to
conservation of resources theory (Hobfoll, 1989), a continued
stress sequelae may also result in resource loss and cascading
effects. Because there are no infinite quantities of positive
adaptational resources, a unique crystallization of personality
style may evolve when adaptive risk feelings are no longer
activated, accompanied instead by reckless, numbed, and
“pathologically brave” attitudes, even to the extent that some
children may become desensitized to danger (Garbarino &
Kostelny, 1993a, 1993b).
Response and coping are likely to depend on a variety of
factors, some of which age related. When trauma occurs
during infancy and toddlerhood, basic trust might be
hindered. Traumas associated with school-age children might
result in nightmares and sleep disturbances, regression and
clinginess to parents or caregivers, loss of concentration/
distractibility and learning difficulties, fearfulness and anxiety,
aggressive behaviors, and even increased propensity for
violence. Adolescents are likely to also display a wide spectrum
of symptoms and coping responses. At a less extreme degree
one can identify anxiety, problems at school and behavioral
problems. These problems, however, may evolve into more
extreme responses such as high levels of aggression and acting
out, numbness to feelings and pain and restricted emotional
development over time, loss of hope characterized by expectation for short life, affiliation with violent groups, high-risk
taking and dangerous behaviors that may harm the
community, and even severe revenge seeking.
With findings coming primarily from institutional and foster
care studies (e.g. Nelson, Zeanah, & Fox, in press; Zeanah
et al., 2003), as well as from examinations of chronic child
maltreatment (e.g. Cicchetti & Valentino, 2006), research
increasingly suggests that trauma may also influence biological
323
regulatory processes. The child’s brain is structured and
neuronally organized by experience, and chronic and severe
stress may influence various systems such as the central
nervous and adrenal-cortical systems, with potential interference with the brain’s high levels of plasticity. Some even
suggest that this may result in pervasive, powerful, and
occasionally permanent effects, deficits and impairments at the
emotional, behavioral, cognitive, and social functioning levels
(e.g. see Couperus & Nelson, 2006; Curtis & Nelson, 2003;
Nelson, 2002; Romer & Walker, 2007; Shonkoff & Phillips,
2000). But what the biological effects of protracted political
violence might be still remains an open question.
In all, some of the responses to violence and trauma are
more self directed, which could be intervened with varied
degrees and likelihoods of effectiveness and success, whereas
other responses might be directed more toward others and the
society at large, in which case interventions are likely to
become more complex and perhaps even less effective. Along
this line, Garbarino & Kostelny (1993a, 1993b) conceptualize
two distinct types of dangers: acute versus chronic. Although
acute danger might be very damaging, we still might observe
responses that can be considered as situationally adaptive
because of their short lived duration. Chronic exposure to
danger, however, may have more far reaching and enduring
implications for developmental adjustment, with possible alterations of personality, major changes in patterns of behavior or
articulation for making sense of ongoing danger – all of which
lead to negative conclusions about the worthiness of the self,
the reliability of adults and their institutions, and the most
appropriate approaches to adopt to the world (Garbarino &
Kostelny, 1993a, 1993b).
Some reactions to chronic danger, such as emotional withdrawal, may appear adaptive in the short run but may become
a source of danger to the next generation. Garbarino, Dubrow,
Kostelny, & Pardo (1998) describe important findings about
children from Cambodia, Northern Ireland and the inner city
of Chicago with respect to moral development. They found that
children exposed to violence who have experienced chronic
trauma became fixated at what they referred to as the vendetta
stage of moral development. Such children do not know how to
reason or express their anger constructively but instead tend to
rely on escalating violence as a tool for survival. In this context
it is useful to refer to the ancient African proverb “It takes a
village to raise a child” that was borrowed by Hillary Clinton
(1996) to imply, justifiably, that a host of various community
based supportive systems are necessary to ensure, on top of the
obvious prerequisite contribution of the family, successful
raising of children and their productive integration into society:
“I chose that old African proverb to title my book because it
offers a timeless reminder that children will thrive only if their
families thrive and if the whole of society cares enough to
provide for them”, Clinton said (1996). So what happens when
the exact opposite takes place and political violence places the
entire community infra structure in jeopardy?
Borrowing some concepts from the fields of epidemiology
and immunology, Garbarino called such devastating
conditions (in particular in the context of chronic exposure to
war and danger) “social disaster” that includes the “toxic”
destruction of daily infrastructures that are so vital for generating positive moral interpretations. Ideas associated with
social toxicity therefore will be used throughout this paper to
assess the Israeli–Palestinian context.
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Effects of wars worldwide
In general, data worldwide show at times of crises consistent
elevated levels of posttraumatic stress symptoms (PTSD),
albeit with varying degrees of depth and rate, as well as
additional mental health problems and psychological reactions
in a wide spectrum of domains and in many war zones. The
list of studies is (unfortunately) rather extensive and addresses
the impact of political violence on: Bosnian-Herzegovian
children (Goldstein et al., 1997; Smith et al., 2002), Cambodian children (Dickason, Him, & Sack, 1999; Kinzie et al.,
1986; Sack et al., 1995), Chinese children and youth (Chan,
1985; Raddock, 1977), displaced children in Croatia (Zivcic,
1993), Iraqi children and youth (Abdel-Khalek, 1997), Kosovo
children and parents in Sweden (Almqvist, & Broberg, 2003),
Kurdish-Iraqi children (Ahmad, 1992; Ahmad et al., 2000;
Punamäki, Muhammed, & Abdulrahman, 2004), Kuwaiti
children during the Iraqi invasion in 1990 (e.g., Macksoud,
Dyregrov, & Raundalen, 1993; Nader and Fairbanks, 1994;
Nader, Pynoos, Fairbanks, Al-Ajeel, & Al-Asfour, 1993),
displaced Iranian children (Kalantari, Yule, & Gardner, 1990),
Lebanese children during the civil war in Lebanon (Macksoud,
1992; Macksoud and Aber, 1996; Saigh, 1989, 1991), children
and youth experiencing the war Northern Ireland (Blease,
1983; Ferguson & Cairns, 1996; Lyons, 1974; Muldoon, &
Trew, 2000), South African youth (Dawes, Tredoux, &
Feinstein, 1989; Fassaert, 1992; Straker, 1992), and South
American children (Cervantes et al., 1989). It should be noted
that although the list of studies reporting negative effects is
indeed long, still some recent reviews have suggested that not
always can we find negative associations between exposure to
political violence and various functioning outcomes (e.g.,
Cairns, 1996; Cairns & Dawes, 1996; Jones, 2004; Muldoon
& Trew, 2000; Shaw, 2003).
The aforementioned review of the nature, scope and level of
trauma suggests that various outcomes may be discerned
depending on the definition used for traumatic effects (e.g.,
PTSD or some types of psychopathology, distress reactions,
anxiety and the like) and the context of its evaluation.
Moreover, studies vary in their methodology; very often relying
on self-reports and telephone surveys and sometime even on
the basis retrospective appraisal; sometime on the basis of
convenience and clinical samples, and often with objective
difficulties to include appropriate comparisons or reported
norms with which to compare areas, hence resulting in merely
within-group designs without a reference point to compare the
findings either with non-exposed groups or with existing
normative data – but at least some of these studies help us shed
light on the role of individual differences.
Also many of the studies take a one-dimensional rather than
a multi-dimensional approach (e.g. focusing on self reported
psychological assessment with no further external information
about the participants’ functioning and other important
indices such as day to day routine engagements like work and
community activities), and often generating questions that are
bound to yield negative outcomes, most of which without
longitudinal data.
At the same time one should not over criticize the state of
the art because war studies are difficult to carry out and
sometime even inappropriate for research within certain time
contexts and circumstances. And yet, we must look carefully
at inconsistencies given the different regions, nature of
conflict,
conceptualizations,
different
methodologies,
measures, etc. Because some inconsistency may appear in the
data, appraisal of each finding or series of findings needs to be
done with care and within the appropriate context, before we
can draw more firm conclusions about the effects of exposure
to war traumas.
Finally, as discussed before, a distinction must be made
between short-term versus long-term effects. Some work that
has looked at enduring effects of exposure to political violence
suggests that negative effects tend to decline and disappear
even in war zones that induced extremely high level of violence
and hostility, including for example Bosnian adolescents
(Becker, McGlashan, Vojvoda, & Weine, 1999), Cambodian
adolescents who left to Canada (Rousseau, Drapeau, &
Rahimi, 2003) and South African children (Braungart &
Braungart, 1995; Setiloane, 1991). Such a differentiation is
essential, especially when one is interested in underpinning the
effects of exposure to chronic-intractable conflicts, and therefore it will become an integral part of our evaluation of the
work done in Israel and the Palestinian territories. It should be
noted that the two sides name the Arab–Israeli wars differently
(for a review of the conflict see Morris, 2001) and, therefore,
when the wars are reviewed in an Israeli or Palestinian
contexts, the Israeli and Arab terminologies are employed
respectively. To illustrate the different meaning the two sides
attribute to the wars, Table 1 depicts both the Arab and Israeli
titles of the various wars.
The Israeli case
Israel has been part of an intractable conflict for six decades,
since its foundation in 1948. Despite the conflict’s longevity
and potential psychological implications, the scope of research
on the psychological impact of the conflict is sparse with the
possible exception of the more extensive research around the
Gulf War. This should not be surprising because during Israel’s
Table 1
Major wars in the Arab–Israeli conflict 1948–2006
Year
1948
1956
1967
1973
1982
1987–1993
2000–2005
2006
Name of war (by Israelis)
Name of war (by Arabs)
War of Interdependence
Suetz War/Operation Kadesh
Six Day War
Yom Kippur War
Operation Peace for the Galilee (First Lebanon War)
Intifada
Al Aqsa Intifada
Second Lebanon War
Al Nakba (catastrophe)
Sinai War/the tripartite aggression
1967 War/June War/Al Naksa (the setback)
Ramadan War or October War
The Invasion
Intifada (uprising)
Al Aqsa Intifada
The Lebanon Invasion
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first several wars (in particular, the Independence War, 1948;
Operation Kadesh, 1956; Six-Day War, 1967), the country was
still not sufficiently aware of the emerging need to assess the
conflict’s psychological effects, nor did it have sufficient
resources and established academic infrastructures for
conducting such research.
The Six-Day War in particular created strong feelings of
euphoria among Israelis that certainly distracted interest from
studying the effects of the war on its children. Also, the limited
number of studies might reflect an ethical understanding that
during war time it is inappropriate to carry out such research
with children, especially when the country is preoccupied with
issues of survival and self-defense. The Yom Kippur War and
its negative effects on the mood of the nation opened up the
field, but still to a limited extent.
With this in mind, the current review is based upon data
derived from war-related studies over all Arab-Israeli wars.
Specifically, I rely upon work associated with the Six Day War
(1967), Yom Kippur War (1973), Operation Peace for the
Galilee (1982–1985), non specific artillery shelling between
wars, the Gulf War (1991), as well as the two Intifadas
(1987–1993, 2000–20051 respectively). At present no data are
available for the second War in Lebanon (summer 2006). For
the convenience of the reader a summary of each of the studies
reviewed below is presented in Table 2.
Meijer (1985) reports data about children who were born
and examined in1967 and who were reexamined at the end of
the first grade of elementary school. It was reported that “war
children” as compared with those born after the war had
significantly more developmental delays and regressive, nonaffiliative and dissocial behavior. The author consequently
concluded that a disturbed mother–child relationship existed
in the war group. However, when the sample, design and
statistical analyses, as well as various other non significant variables, are examined, it could be the case that the (few) significant findings reported merely capitalized on chance. Although
the 6 years post war data seem to suggest impressive longitudinal negative effects, the various limitations of the study
suggest that we should be cautious about the study’s far
reaching conclusions.
Ziv, Kruglanski, & Shulman (1974) examined the psychological reactions of Israeli children living in border settlements
that were under frequent artillery shelling following 1967. The
main findings showed that shelled children expressed more
patriotism and signs of courage than did non-shelled children.
Interpretation of these data, in time perspective, may suggest
that children who had to take cover in shelters used more patriotism and expression of courage as a coping mechanism –
which was rather typical and acceptable in a society that
developed social norms that strongly justified the Six-Day War
and which was rather proud about the victory. Also comparing
shelled versus non-shelled Israeli children, Ziv and Israeli
(1973) found in both groups low level of anxiety. It appears
that studies of Israeli children exposed to artillery shelling have
discovered only limited signs of anxiety or other psychological
malfunctioning – at worst with only transient rise in distress.
1 The Al-Aqsa Intifada never officially ended. February 2005 is used by some
as a turning point when Mahmoud Abbas was elected President of the Palestinian National Authority and met with Israel Prime Minister, Ariel Sharon, at
Sharm-el-Sheikh where both sides announced an end to the violence. It is still
debatable whether the events after February 2005 should be considered part of
the Intifada or as independent events (www.GlobalSecurity.org).
325
As for the Yom Kippur War (1973), Milgram and Milgram
(1976) compared data collected on 5th and 6th graders before
the war’s eruption and about two months thereafter. The
general anxiety of the children nearly doubled from time of pre
war to time of war. It should be noted that the study is
restricted in scope because all children were recruited from
only two schools in Tel Aviv and its generalizabililty is therefore limited. One should also remember that the Yom Kippur
War was perceived, during many of its initial phases, as potentially leading to a forthcoming catastrophe for Israel, hence
resulting in a national mood of declining confidence and
security, which may in part explain the powerful increase in
level of anxiety. The authors suggest therefore that the rise in
anxiety during the Yom Kippur War is normative, but they also
suggest that it was associated with only transient effects,
especially given other data showing that, despite the preceding
the Six-Day War and the War of Attrition (1968–1970), Israeli
children at time of relative calm are as low in anxiety as
American counterparts. Milgram and Milgram’s (1976) report
is consistent with Kaffman’s work (1977) on kibbutz children
under war stress, suggesting that during the Yom Kippur War,
the kibbutz network was able to develop and rely upon organized group cohesiveness as measures that facilitated reduction
in the severity of reactions to stress and psychiatric symptomatology among children and adult members of the kibbutzim.
Information about the War in Lebanon (1982–1985) and its
effects on children is also limited. Existing research is found
with adult populations along two lines. The first primarily
focuses on the long term combat effects on soldiers, with data
examining various aspects, including individual differences
such as coping, locus of control and social support as they
relate to combat-related posttraumatic stress disorder
(Solomon, Mikulincer, & Avitzur, 1988) as well as the
enduring effects 20 years post war, especially in combat stress
reaction casualties (Solomon & Mikulincer, 2006). It should
be noted though that the majority of the comparison veterans
who participated in this study did not exhibit PTSD, suggesting that soldiers directly engaging in combat activities may
have sufficient resilience to cope with such traumatic experiences. It is important to note that the Israeli military is
comprised of soldiers who fulfill their mandatory service
(18–21 years of age) as well as those who are on their reserve
duty (approximately 21–50 years of age). Therefore, these
findings and conclusions represent the entire military population that participated in the first War in Lebanon.
The second line of research during the war in Lebanon is an
evaluation of what was referred to as “Pulse of a nation:
Depressive mood reactions of Israelis to the Israel-Lebanon
War” (Hobfoll, Lomranz, Eyal, Bridges, & Tzemach, 1989).
This work is based on eleven national Israeli samples concerning the mood in Israel over 11 occasions between 1979 and
1984, and it consisted of interviews prior to, during, and
following the 1982 War in Lebanon. The research group also
evaluated major newspaper headlines that appeared concurrent to each national sampling, so that the relationship between
major national events and depressive mood could be explored.
The results appeared to fluctuate, with an increase in depressive mood during the war’s outbreak followed by a decline in
depressive mood subsequent to the most intensive period of
the war, which, the authors suggested, is indicative for adaptation that may take place in reaction to continued stressful
circumstances. The authors also reported a peak in depressive
mood when the massacre of Palestinians at the Sabra and
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Table 2
Summary background of studies in Israel
Author
War
Age
Design
Measures
Meijer (1985)
Six-Day War
Infants (Time 1)
7-year (Time 2)
Quasi-experimental –
longitudinal (war children
vs. non-war children)
Various aspects of early
development, social and asocial
behavior
Ziv, Kruglanski, & Shulman
(1974)
Shelling between
wars
4th, 5th, 6th, 7th, and 8th
graders
Quasi-experimental
(shelled vs. non-shelled)
Local patriotism, covert
aggression, appreciation of
courage
Ziv & Israeli (1973)
Shelling between
wars
10-year-olds
Quasi-experimental
(shelled vs. non-shelled)
Anxiety
Milgram & Milgram (1976)
Yom Kippur War
5th and 6th graders
Pre- and post war
Anxiety
Kaffman (1977)
Yom Kippur War
Age not specified
Clinical report
Clinical report about reactions
to stress and psychiatric
symptomatology
Solomon, Mikulincer, &
Avitzur (1988)
Peace for the
Galilee (1982
war in Lebanon)
Young adults
Individual differences
(correlational)
Coping, locus of control and
social support explaining
combat-related posttraumatic
stress disorder
Solomon & Mikulincer
(2006)
Peace for the
Galilee
Young adults
Longitudinal – 20 years
follow up
Combat stress reaction and
PTSD
Hobfoll, Lomranz, Eyal,
Bridges, & Tzemach (1989)
Peace for the
Galilee
Young adults
11 national samples
Cross-sectional (before,
during, after the war)
Depressive mood
Hoffman & Bizman (1996)
First Intifada
4th and 9th graders
Cross-sectional
Pessimism–optimism
Solomon (1995)
Gulf War
Different sampling and
recruitment procedures
Review of all studies
different research designs
(with and without control,
cross sectional,
mini-longitudinal)
Different procedures and
measures (interviews, self
report, telephone surveys,
retrospective data collection)
Laor et al. (1996)
Gulf War
Preschoolers
Individual differences
(correlational)
Association between family
cohesion and symptomatic
reaction
Laor & Wolmer (2000)
Gulf War
8–10 years old
Individual differences
(correlational)
Capacity for image control as a
protective factor against long
term effects of trauma
Schwarzwald et al. (1997)
Gulf War
5th, 7th, and 10th graders
Individual differences
(correlational)
Association between
posttraumatic symptoms and a
sense of future orientation
Slone, Adiri, & Arian (1998)
First Intifada
(post Gulf War)
6th and 7th graders
Comparing Israelis vs.
Palestinians
Exposure to political stressors
Slone (2008); Slone, Lobel,
& Gilat (1999)
First Intifada
(post Gulf War)
6th and 7th graders
Individual differences
(correlational)
Association between exposure to
political stressors and reported
distress
Shalev et al. (2002)
Al-Aqsa Intifada
Adults
Select, non-representative
survey
Self report PTSD symptoms
Yagur, Greenspoon, &
Ponizovsky (2002)
Al-Aqsa Intifada
Adults
Select, non-representative
survey
Self report PTSD symptoms
Somer, Ruvio, Soref, & Sever
(2005)
Al-Aqsa Intifada
Adults
Comparison (more and
less affected areas)
Telephone survey (mood,
posttraumatic symptoms, and
coping strategies)
Bleich, Gelkopf, & Solomon
(2003)
Al-Aqsa Intifada
Young adults
Representative strata
sampling
Telephone survey (traumatic
stress-related and PTSD
symptoms, sense of safety)
Demb (2006)
Al-Aqsa Intifada
Adolescents
Exploratory
Coping and resilience
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Table 2
Continued
Author
War
Age
Design
Measures
Solomon & Lavi (2005)
Al-Aqsa Intifada
12–15 years old
– Comparison (more and
less proximate
neighborhoods to
Palestinian zones)
– Individual differences
(correlational)
– Self report posttraumatic
symptoms, future orientation
toward peace
– Association between exposure
to political violence and
attitude toward peace
Shamai & Kimhi (2006)
Al-Aqsa Intifada
Adolescents
Individual differences
(correlational)
Association between exposure to
political violence and attitude
toward compromise
Bleich et al. (2003)
Al-Aqsa Intifada
Adults
Telephone survey
Traumatic related symptoms,
sense of safety with respect to
self and significant others, future
orientation
Shatilla refugee camps took place, which seems to be rather
normative response under such circumstances. In all, these ups
and downs seem to be rather appropriate and normative as far
as anticipated increase and decrease in the level of depressive
mood along the various events that took place.
Chronologically, the next major war related experience of
Israelis is the first Intifada (1987–1993). Not much research is
associated with this Intifada, excluding the period of the Gulf
War that coincided with the timing of the Intifada (see below).
It should also be noted that, for the most part, the Intifada’s
immediate consequences for Israeli children are rather remote,
because it consisted primarily of a direct confrontations
between Palestinians and the Israeli military in the occupied
territories.
One study addressed the attitudes toward war and peace of
4th and 9th graders during 1989 Intifada (Hoffman, & Bizman,
1996). In a nutshell, the data portray a complex duality:
pessimism regarding the likelihood of reducing hostility on the
one hand, and a great deal of optimism regarding the prospects
of peace on the other hand; in the mind of these children we
therefore observe a mixture of anger mingled with hope. It
should be noted that these are group data about how Israeli
children and adolescents attribute explanations and causes to
the conflict and its prospect. Such supposedly conflicting data
may be seen as reflecting the complexity of the ecology and
perhaps these “conflicting” findings may be accounted for also
by existing individual differences that were not explored in this
study. Perhaps some children and youth may be more at the
positive side and it is these participants who might have
contributed to the appearance of the hope dimension, whereas
some may be positioned more on the negative side and thereby
affecting the pessimistic dimension.
The Gulf War and the Scud attacks on Israel during the
winter of 1991 were extraordinary and frightening for most
Israelis. In fact, this was a war between the United States and
Iraq and the Israeli population found itself immersed in that
war indirectly and passively. Israel was requested (or forced)
by the US to sit aside passively despite Iraqi Scud missiles
hitting Israeli civilian population centers. Because of the threat
of unconventional weapons, Israelis had to seal their homes
and wear gas masks when the attacks took place. It is not
surprising, therefore, that this war attracted a number of
mental health researchers who assessed the influence of the
attacks on all segments of the population: children and their
parents, adults and elderly. Indeed, this Gulf War’s uniqueness
resulted in the production of many publications, more than
have been generated in any of the other wars or Intifadas.
It is not surprising that initial psychosocial reactions were
observed as natural short term responses, but were they only
transient and eventually adaptive in the most part? And how
about enduring effects and more long lasting traces of this
traumatic experience? Solomon (1995) has provided a
comprehensive and excellent account of the scientific work
conducted around the effects of the Gulf War, and subsequently there is no need to detail here various aspects of the
available studies. My own appraisal of the existing research
converges fully with Solomon’s account. Therefore, I will refer
only to the main directions and will also reiterate at least one
specific dimension that seems to be critical to my global review
and analysis in this paper, namely the place of individual differences in the Gulf War body of research and in studies of the
effects of wars in general.
Taken together and with only few exceptions (e.g., Rosenthal and Levi-Shiff, 1993 with infants/toddlers and their
mothers), as Solomon’s concludes, the Gulf War did not have
any profound effect on the Israeli population at large, certainly
not in terms of enduring negative outcomes. It should be noted
that that different studies employed different sampling and
recruitment procedures (i.e. representative, clinical,
convenience), different research approaches (quantitative
versus qualitative), different procedures and measures (e.g.,
interviews, self report, telephone surveys, retrospective data
collection, just to name a few) and different research designs
(i.e. with and without control, cross sectional, mini-longitudinal). Keeping in mind the aforementioned diverse methodological approaches, the picture nevertheless seems to be rather
clear and uniform, pointing to the fact that the Israeli society
coped rather adaptively without showing substantial signs of
psychopathology and unusual malfunctioning. Most studies
showed some degrees of distress, which is rather expected in
such an uncertain situation, especially with the threat of
biological and chemical attack. But both adults and children
maintained adaptive control and those initially observed transient stressful reactions evaporated rather rapidly, and various
community services, including the school system, were quickly
reopened and returned to normative operation.
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Although there were several casualties as well as destruction
of some private housing and public facilities, children and
adults did hardly experience witnessing direct losses, injuries
or physical damage. There was no shortage of food or any other
necessities, the families remained intact during the Scud
attacks themselves, and the media played a very positive role –
all of which ensured a rapid and smooth return to normal and
normative routines that eventually helped maintain rational
decisions and prevent disorganization.
A number of studies also looked at the differential effects of
the Gulf War on basic individual differences in parental capabilities as well as in children characteristics. For example, Laor
et al. (1996), in their examination of the differential effects of
traumatic displacement following a Scud missile attack, found
inadequate family cohesion to predict symptomatic reaction in
preschoolers. Laor & Wolmer (2000) also found that a higher
capacity for image control by children displaced due to the
destruction of their homes after the missile attack on Tel-Aviv
served as protective factor against the long-term effect of
trauma, hence pointing to individual difference in the plasticity among children. For a somewhat different outcome,
Schwarzwald et al. (1997) found with 5th, 7th, and 10th graders
that future perception was basically positive, but, once again,
with individual variability showing an association between
posttraumatic symptoms and a sense of future orientation.
The couple of years following the Gulf War there remained
the challenge of coping with the first Intifada in Israeli society,
and again relatively little research of psychological domains
related to the Intifada can be found, especially as it pertains to
the well being of children. One study comparing Israeli
children and Palestinian children in Gaza (Slone, Adiri, &
Arian, 1998) shows that Palestinian children reported significantly greater exposure to political stressors. Most of the Israeli
children (74%) reported low to moderate exposure to political
life events and only 3% reported very high exposure. In
contrast most Palestinian children reported high to very high
levels of exposure (72%). Also for the Israelis, a linear relation
was found between increased severity of political life events
exposure and level of reported distress (Slone, 2006; Slone,
Lobel, & Gilat, 1999), which points again to the role of individual differences and variability; not all children are similarly
affected by the events. Some children perceive the events as
stressful, but, at same time, other children do not appraise the
events as stressful and therefore report low level of distress.
A growing body of research can be seen with regard to the
Al-Aqsa Intifada, again with a mix of more carefully versus less
carefully designed studies, which, of course, influences the
nature, quality and validity of the findings. Shalev et al. (2002)
describe a select, non-representative survey with adults that
took place between October 2000 and July 2001(immediately
after the eruption of the Al Aqsa Intifada) in a settlement near
Jerusalem, showing PTSD symptoms when there is a continuous exposure to stress. They suggest that the fears may be
focused and real thereby protecting the individual and preventing exposure to danger, but, by and large, without necessarily
affecting functioning. A similar trend has been reported by
Yagur, Greenspoon, & Ponizovsky (2002) on the basis self
reports made by a select sample in a primary care physician
clinic in Gilo, a Jerusalem neighborhood that had been under
frequent, sometimes intense gunfire emanating from the neighboring Palestinian Authority areas.
In another telephone survey with a sample of adults (60%
response rate), purposely over-representing more damaged
areas, the researchers assessed level of exposure to terrorism
for individuals residing in more and less affected areas, along
with their psychological responses and coping strategies during
the peak of the violence. Extreme reactions were reported
(Somer et al., 2005), especially with adults residing in the most
frequently targeted zones, but the authors say that “the effects
of major national trauma were not limited to those directly
exposed to it”. Indeed some mood measures, what they refer
to as the national mood in Israel, appeared to be unrelated to
the level of exposure to terrorism, namely those who had been
traumatized directly were no more likely to develop a negative
mood than other citizens. The authors conclude that the terror
campaign against Israel touched the lives of many Israelis and
negatively affected the general mood of many, regardless of
place of residence. At the same time this is a mood assessment
and, naturally, mood can and should be affected by the
conflict, but when it comes to stronger psychological response,
adults residing in the most severely hit neighborhoods were
also those who suffered most from posttraumatic symptoms.
In an attempt to determine the magnitude of exposure to
terrorist attacks and the prevalence of traumatic stress-related
and PTSD symptoms, and sense of safety after 19 months of
terrorism in Israel (since the eruption of the Al Aqsa Intifada),
as well as to also identify correlates of the psychological
sequelae and the modes of coping with the terrorism – one
more telephone survey was conducted in April–May 2002,
employing a strata sampling method with a representative
sample of Israeli residents older than 18 years (57% response
rate), and provided further information about rates of distress
and PTSD (Bleich et al., 2003). It should be noted that the
survey participants indeed showed distress and lowered sense
of safety with regard to themselves and their relatives, but at
the same time very few reported a need for professional help
with a majority of respondents expressing optimism about
their personal future, the future of Israel, and about their selfefficacy with regard to their ability to function after a terrorist
attack. The authors suggest that given the nature and duration
of the Israeli traumatic experience, the psychological impact
may indeed be considered as somewhat moderate, with no
apparent high levels of psychiatric distress, all of which imply
adaptive coping processes.
Thus far, data has been reported about adults in the context
of the Al Aqsa Intifada. Demb (2006) examined the relationship between multiple protective factors at the individual,
social, and familial levels, and the resilience displayed in a large
sample of Israeli adolescents. The prevalence of resilient individuals found in her study (76%) is consistent with other data
reported thus far about adults’ capacity to cope rather adaptively, even under continued stressful events and the devastating experiences of the Intifada.
In the summer of 2001, a most pertinent study with
adolescents from Jerusalem, Gilo, and the Jewish settlements
in the occupied territories examined the relationship between
exposure to political violence and posttraumatic symptoms,
future orientation, and attitudes toward peace (Solomon &
Lavi, 2005). A higher percentage of youths in the settlements,
as compared with Jerusalem or Gilo, reported moderate to very
severe levels of posttraumatic symptoms. At the same time,
adolescents’ future orientation responses were moderately
optimistic. Moreover, exposure to political violence was found
to be related to both PTSD symptoms and to attitudes toward
peace, but not to future orientation. In fact, the association
discerned between level of exposure and attitudes toward
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peace talks suggests that youths are likely to become more open
to peace negotiations once a decline in violence is more
evident. Thus as the authors propose, these findings seem to
reflect a complex interrelationship of political violence, posttraumatic stress symptoms, and attitudes toward peace, ultimately raising the quest for combining mental health
considerations with peace related issues – which are exactly in
the core of the present paper.
Importantly, Solomon and Lavi (2005) go on to propose
that one must appraise the heterogeneity in youth attitudes
toward peace talks. From a traditional human development
point of view, we can clearly witness here individual variability rather than a uniform homogeneous group that rejects
peace. Such expected developmental variability is well reflected
in Shamai and Kimhi’s findings (2006) showing that the lower
the level of exposure to political violence the greater the
support for political compromise, as well as in Solomon and
Lavi’s (2005) findings which also show that negative attitudes
toward the peace talks were associated with increased levels of
exposure.
The Al Aqsa Intifada is perhaps one of the most horrible
experiences with which Israelis have had to cope since the
founding of Israel. The Intifada has drastically changed life in
Israel, and when an actual suicide bombing happens, the
damaged scene looks unimaginable and inhuman, so hard to
describe, share and absorb. Bleich et al. (2003) have shown
that as a result of this Intifada, Israelis experience a lowered
sense of safety with respect to themselves and their significant
others. Yet despite all these adversities, as outlined by Bleich
et al. (2003), we still observe an overall consistent line of
optimism, and individual as well as communal resilience. The
strongest factor to account for these phenomenal capacities
appears to be a very solid family and community infrastructure. Thus the data suggest an impressive capacity of many
Israelis to cope and maintain life’s routines intact.
In fact, already during the mid 80s, before the eruption of
the Intifadas, Milgram (1982, 1986) attributed the relatively
low stress responses of Israeli children to the social norms,
social cohesiveness, and support that developed in the different communities. The present review of war-related research
on Israeli children and adults over the past five decades
suggests that even when the intractable conflict with the Palestinians continues and the threat of suicide bombings is ongoing
– some members of the population react in times of crises with
varying degrees of normative distress, for the most part with
little severe PTSD symptoms or psychological or behavioral
problems, which most often might be transient and disappear
over time. From a developmental and adaptational point of
view, future research should focus more directly on those
children who remain resilient after experiencing war-related
atrocities.
Wiener (2004) observes that when a terrorist attack
happens, the immediate response is one of anger, anxiety, and
depression. This is to be expected as part of the human
development repertoire. Relatively soon thereafter all these
natural reactions seem to weaken and even disappear, at least
for the majority of the population that has not been directly
affected or harmed by the event (those directly affected are
usually a small minority). To a large extent, as Wiener
proposes, such resilience is apparently associated with well
formed individual and societal infrastructures such as a functioning labor market, schools, health systems, active shopping
malls, various community services including synagogues,
329
youth movements, and extra curricular activities for children –
in all, infrastructures that create a more or less continuous
sense of “business as usual”.
So the availability and sustainability of solid infrastructures
at all societal levels, and a desire and capability of most people
to rely upon these layers of infrastructures, may have created
a well adapted synergy, apparently transformed into flexible
and resilient mental health infrastructures. And above all,
research has shown a wide spectrum of individual differences
in adaptation capacities, making it possible that at least some
people may be more resilient in their coping even under the
most disastrous of circumstances.
The Palestinian case
Most of the data evaluated in this section has been produced
by a group of researchers and professionals at the Gaza
Community Mental Health Program (GCMHP), often in
cooperation with the Finish psychologist Punamäki (see this
volume). The GCMHP group should be commended for
conducting important work during times of great adversity,
providing the international community with critical information about vulnerability and resilience of individuals living
under extremely hazardous life conditions. A large portion of
the findings reported here is based on waves of data collected
during and following the first and second Intifadas (for more
information, see Qouta, Punamäki, & El Sarraj in this volume).
Of course, the work of other researchers will also be examined
(see Table 3 for a summary of all reviewed studies).
An additional important point to make at this time is about
the nature of measurements employed to assess the well being
of children and families. Naturally, from a mental health
perspective, one is interested in looking at measures such as
PTSD, depression, anxiety, and other related symptom
measures. But equally important is also the need to explore
resiliency factors that can help children cope under extreme
conditions, sometimes even catastrophic circumstances of
foreign occupation. Thus other measures become pertinent,
including parental role and functioning, social networks,
community services, political engagement and activity, and a
host of other day-to-day variables that do not necessarily fall
within the realm of traditional psychological symptomatology.
The research in the Palestinian territories has adapted to this
broad spectrum of variables.
To the best of my knowledge, the first internationally
published study about the psychological well being of Palestinian children appeared in the late 1980s (Punamäki, 1988).
The timing of this study is important for our purposes. In
general, her study shows that children are not necessarily
helpless and that oppression might lead to activism even
among children 8–14 years old, with older kids showing more
activism. At the same time she found some differences associated with the time context. Palestinian children (N = 42)
observed in the West Bank in 1985, which is after the invasion
of Israel to Lebanon, were found to show more signs of
perceived helplessness as compared with a group (N = 66)
assessed in 1982 (before the war in Lebanon). Thus, in time
perspective, the invasion to Lebanon by Israeli military troops,
although not taking place at Palestinian territories but at neighboring Arab territories, had negative effects upon Palestinian
children. Recall that we talk here about the pre-Intifadas era,
so that timing becomes an important player developmentally,
and the eruption of the first Intifada can be seen as a case in
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Table 3
Summary background of studies in the Palestinian territories
Author
War
Age
Design
Measures
Punamäki (1988)
Before and after
the 1982 Invasion
to Lebanon
8–14 years old
Cross-sectional (before
and after the war)
Coping modes
Baker (1990)
First Intifada
6–15 years old
Descriptive, individual
differences (correlational)
Locus of control, self-esteem,
psychological symptomatology
Baker, & Kanan (2003)
First Intifada
6–15 years old
Descriptive, comparison
under various proximity
distances to military fire
zones
PTSD symptoms, depression,
self-esteem
Barber (2008a, 2008b)
First Intifada
20–27 years old
Descriptive
Political activism,
felt-victimization, perceived
meaning of experiences, various
psychological indicators,
personal growth
Haj-Yahia (2008)
First Intifada
14–20 years old
Descriptive survey,
comparison under various
levels of exposure to
military attacks
Internalizing and externalizing
symptoms
Khamis (2005)
(Post) First
Intifada
12–16 years old
Descriptive, individual
differences (correlational)
PTSD symptoms, family
ambiance and parental discipline
Qouta, Punamäki, & El Sarraj
(1998)
First Intifada
Parents and their
7–11-year-olds
Comparison under various
traumatic experiences
Anxiety scale, MMPI,
children’s psychological
symptoms
Punamäki, Qouta, & El Sarraj
(1997a, 1997b)
First Intifada
11–12 years old
Individual differences
(correlational)
Perceived parenting styles,
children’s resources, political
activity, psychological
adjustment
Qouta & El Sarraj (1994);
El Sarraj & Qouta (2005)
First Intifada
8–14 years old
Descriptive under curfew
experiences
Externalizing and internalizing
symptoms
Qouta, Punamäki, & El Sarraj
(1995)
First Intifada
11–12 years old (Time 1)
12–13 years old (Time 2)
Individual differences
(correlational) and
longitudinal (one year) –
pre- and post Oslo Treaty
Political activity, psychological
resources and wellbeing
Qouta, Punamäki, & El Sarraj
(2001);
Qouta, Punamäki, & El Sarraj
(2001)
First Intifada
10–12 years old (Time 1)
13–15 years old (Time 2)
Individual differences
(correlational) and
longitudinal (three years)
– pre- and post Oslo Treaty
Political activity, mental flexibly,
psychological adjustment, PTSD
symptoms, emotional disorders
Abdeen, Qasrawi, Shibli,
& Shaheen (2008)
Al-Aqsa Intifada
14–17 years old
Descriptive survey,
comparison under various
levels of exposure to
military attacks
PTSD symptoms, somatic
complaints
El Sarraj & Qouta (2005)
Al-Aqsa Intifada
12–14 years old
Descriptive
Identifying with “Martyrdom”
Lavi & Solomon (2005)
Al-Aqsa Intifada
12–14 years old
Comparison of
Palestinians living in Israel
and in the occupied
territories
Anxiety, depression, anger,
PTSD symptoms, future
orientation
Qouta, Punamäki, & El Sarraj
(2003, 2005)
Al-Aqsa Intifada
Mothers and their
6–16-year-olds
Descriptive and individual
differences (correlational)
PTSD symptoms and mental
health indicators
Qouta & Odeh (2005)
Al-Aqsa Intifada
School age (age not
specified)
Descriptive
PTSD symptoms and various
symptomatology indicators
Qouta (2004)
Al-Aqsa Intifada
10–19 years old
Descriptive survey
PTSD symptoms
Qouta & El Sarraj (1994)
Al-Aqsa Intifada
10–19 years old
Descriptive survey
PTSD symptoms
Shalhoub-Kevorkian (2006)
Al-Aqsa Intifada
14–19 years old
Qualitative
Feelings of anger and resistance,
sense of potency and control
Thabet, Abed, & Vostanis
(2002)
Al-Aqsa Intifada
9–18 years old
Quasi-experimental
PTSD symptoms, anxiety
Thabet, Abed, & Vostanis
(2004)
Al-Aqsa Intifada
9–15 years old
Descriptive and individual
differences (correlational)
Exposure to traumatic events
and PTSD symptoms
Thabet, Karim, & Vostanis
(2006)
Al-Aqsa Intifada
3–6 years old
Comparison under various
traumatic experiences
PTSD symptoms and various
symptomatology indicators
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point to illustrate that reactions might change from more helplessness, as was the case after the war in Lebanon, to more
activism – as is the case with the eruption of the first Intifada.
This issue will be discussed in the following sections.
When we shift to studies that address the effects of living
under prolonged occupation as well as that of the Intifadas, it
generally should not be surprising that we find high prevalence
of psychological symptoms and reactions in the Palestinian
territories, a zone which is continuously exposed to severe
adversities. In this regard, Qouta, Punamäki, & El Sarraj
(2005) assessed the prevalence and determinants of PTSD
among 121 Palestinian mothers and their young children, all
living in areas of bombardment, none of whom had previous
mental health problems. The results showed high rates of
PTSD signs with various degrees of severity (e.g., 54% severe,
34% moderate and 11% mild or questionable). There was also
a significant link between the mental health of mothers and
that of their children, namely, when mothers’ psychological
problems increased, children’s problems also did.
In a different study of 547 school-age children exposed to
traumatic events, 63% were reported as having full posttraumatic stress symptomatology (Qouta & Odeh, 2005). In
addition, the prevalence of attention problems, lack of concentration and hyperactivity, sleep and speech problems as well
as aggressive behavior rose during the Al-Aqsa Intifada to
approximately 13%–14%. In a recent GCMHP study, Qouta,
Punamäki, & El Sarraj (2003) reports that only 2% of
Palestinian children showed no symptoms of PTSD whereas
9% displayed light symptoms, 34% developed medium level
symptoms and 55% suffered from PTSD. Although it is not
clear from the report whether comprehensive psychiatric
assessments were conducted, such findings are indeed
worrying even if the potential bias of self-reported assessments
is taken into consideration. In another recent research project
(Qouta & Odeh, 2005) on 944 children in Gaza (mean age =
15.1), results revealed a high level of PTSD: about third of the
children suffered from severe level of PTSD symptoms.
At the same time Qouta (2004) states that in their observations they were able to discern signs of coping. For instance,
he proposes that many children’s drawings, showing how
children raising the Palestinian flag in front of Israeli tanks, can
be seen as an indication that they can cope with the trauma by
maintaining a sense of identity and pride, despite fear and
anxiety. Along similar lines, Baker (1990) in his study of 5–16
year-old Palestinians experiencing the first Intifada in refugee
camps, villages and towns in both the West Bank and the Gaza
Strip suggests that active participation in the conflict may
enhance self-esteem and protect children from the development of negative psychological symptomatology. Qouta further
points out that as professionals they realize how difficult it is
to be a parent in the Palestinian environment, especially when
parenting means providing a secure base and a haven of safety
to ensure normal growth. He nonetheless reports that in all
GCMHP research projects, Palestinian parents are found to do
their utmost to produce a secure environment for their
children.
Most of the research with Palestinian samples focused on
school children and adolescents, with little reported research
into the effect of war on the well-being of pre-school children.
In one of these studies, Thabet, Karim, & Vostanis (2006)
investigated in 3–6 years old children the relationship between
exposure to traumatic events and emotional problems. They
found that exposure to traumatic events, such as raids and
331
shelling of the children’s houses, was associated with various
behavioral and emotional problems, and as such, the findings
are consistent with those of previous studies in this age-group
areas of war with Lebanese pre-school children (e.g. Zahr,
1996) and with displaced Israeli pre-school children after Iraqi
Scud missile attacks (Laor et al., 1996).
Thus far we have observed that within normative samples
children living in a war zone like the Gaza strip are at high risk
of displaying signs of PTSD and depressive symptoms. The
GCMPH group has also reported data about some effects of
more specific types of adversities. One study about the effects
of house demolitions (Qouta et al., 1998) examined the effects
of losing one’s home, as well as witnessing the demolition of
others’ houses, on the mental health of Palestinian adults and
children.
The main findings showed that adults exposed to a house
demolition exhibited a higher level of anxiety, depression, and
paranoiac symptoms, when compared with witnesses and
controls. Similar to adults, children in the loss group also
showed a higher level of psychological symptoms when
compared to witnessing children and controls. The authors
note, however, that the study is limited due to its reliance on
self-report measures and lack of psychiatric interviews or
family measures.
Similar findings with 9–18 year-old children and adolescents
are reported for those exposed to home bombardment and
demolition during the Al Aqsa Intifada compared with controls
(Thabet, Abed, & Vostanis, 2002). In this regard, proximity to
areas of military attacks was found to be associated with
increased rate of depression (Baker & Kanan, 2003) and place
of residence, mainly refugee camps, was associated with higher
rates of PTSD symptoms during the first Intifada (Khamis,
2005). Also, in two large survey samples, one assessing 1185
14–20-year-old adolescents in the West bank following the first
Intifada (Haj-Yahia, 2008) and the other assessing 2100 14–17
year-old youth in the West Bank and Gaza during the Al Aqsa
Intifada (Abdeen, Qasrawi, Shibli, & Shaheen, 2008), more
extensive and severe exposure to Israeli military operations,
was positively associated with more internalizing and externalizing indicators in the first study, as well as with more posttraumatic distress and somatic complaints in the second study.
One more specific adversity studied by the GCHMP group
is curfews and their effects on children (El Sarraj & Qouta,
2005; Qouta & El Sarraj, 1994). The group reports that
experiencing curfews was associated with various negative
psychological outcomes: e.g. 66% of the children began to
fight each other, 54% were afraid of new things, 38% started
to develop aggressive behavior, 19% started to suffer from
bed-wetting and 2% showed speech difficulties. In all, the
authors propose that the conflict’s longevity and the fact that
it is chronic rather than acute may explain the increased rates
of PTSD.
An Israeli research group from Tel Aviv (Lavi & Solomon,
2005) has also examined recently the effects of chronic
exposure to trauma on Palestinian children, showing that
participants who live in the Palestinian territories reported
that they experienced significantly more traumatic events
than did Palestinians who live in Israel. Those living in the
Palestinian Authority also reported higher levels of posttraumatic symptoms as well as more pessimistic future orientation accompanied by less favorable attitudes towards peace
prospects. Clearly, Lavi and Solomon (2005) add several
important dimensions by assessing not only Palestinians in the
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occupied territories but also by comparing them to those Palestinians who live in Israel under much better life conditions.
Moreover, they looked not only at mental health parameters
but also at indices of future orientation, an important observation when one wishes to draw conclusions about the potential link between traumatic experiences and prospects for
peace.
Some of Shalhoub-Kevorkian (2005, 2006) recent qualitative findings with regard to Palestinian children facing the
“security fence” or the “separation wall” (in the Israeli and the
Palestinian terminologies respectively) point to children’s
narratives that emphasize, to a large extent, their struggle
between stressful daily experiences and resilience and coping
strategies. The author suggests that the construction of the wall
added diverse meanings to the way children perceive the world
around them. The data suggest that the wall triggers a great
deal of anger and resistance. Palestinian children describe the
new challenge of how to deal with the wall, by crossing it
despite the physical barriers and by denying its existence with
an attempt to maintain a sense of potency and control rather
than helplessness.
Thus far the review has focused primarily on prevalence and
rates of PTSD and other psychological reactions. Earlier
studies have noted that the consequences of war can be moderated by levels of social support and family dynamics and functioning (Cohen & Dotan, 1976; Laor et al., 1996; Zahr, 1996).
Moreover, maternal capacity to cope with stress was also found
to be an important protective factor (Laor et al., 1997). Along
these lines Punamäki et al. (1997a, 1997b) have carried out,
in real war time conditions, a study that examined various
aspects of individual differences as they interact with effects of
war conditions. Despite the small sample size and primarily use
of self report measures, the study sheds important light on the
role of individual differences in children living under
conditions of violent conflict. In this study too, the results
showed that exposure to traumatic events increased psychological adjustment problems. It should be noted that the higher
the number of traumatic events children experienced, the more
negatively they perceived the functioning capacity of their
parents. Moreover, the poorer they perceived parenting, the
more neuroticism and low self-esteem were reported.
Similarly, in a post first-Intifada study with 12–16 year old
children, Khamis (2005) has found that children who were
reported to have more PTSD symptoms endured more stressful family conditions. Moreover, in a recent research project
(Thabet et al., 2004) with 9–15 year-olds living in four refugee
camps in the Gaza strip during the Al Aqsa Intifada the authors
report a wide list of PTSD symptoms as being differentiated
and predicted by the level of exposure to traumatic events.
Taken together, the major implication is that not all children
react in the same level of severity despite exposure to profound
adversity.
Equally important is the discussion of the interplay between
traumatic events and political activism: The more traumatic
events children reported, the more they were engaged in political activity, and the more politically active they were, the
stronger was their reporting of psychological adjustment
problems (Punamäki et al., 1997a, 1997b). Finally, when
children’s perceptions of their parents were positive, they also
reported better psychological adjustment, hence suggesting
that good parents were perceived as protecting their children.
The researchers suggest that at times of exposure to external
trauma, children and their parents function as a collaborative
unit, the quality of which is predictive of psychological adjustment (Punamäki et al., 1997a, 1997b). On balance, the data
highlights the role of risk as well as protective factors and
suggest that there are no black or white answers even under
conditions of severe war adversity.
Barber’s (2008a, 2008b) extensive series of studies of
adolescents in the Palestinian territories also confirms the
more complex picture portrayed by the Gaza-Finnish team. He
reports data suggesting that youth who have been exposed to
chronic violence as well as engaged actively in political conflict
do not necessarily show an increase in psychological problems,
violence, and aggression. He contends that when studying the
effects of political violence on children and adolescents, we
must appraise the meaning that they attach to the conflict they
experience. Barber suggests that once such perceived meaning is
given more consideration, it might account for those findings
that fail to show dysfunction in children and youth who have
been chronically exposed to political violence. He provides
data suggesting that youth’s political activism, even when
accompanied by violence, has important implications for
positive identity and personal growth.
In a critically important attempt to look longitudinally at the
differential effects during times of heightened political violence
versus times of more peaceful expectations, Qouta, Punamäki,
& El Sarraj (2001) and Qouta et al. (2001) examined the
effects of cognitive capacity, perceived parenting, traumatic
events, and activity, which were first measured in the midst of
the political violence of the Intifada in 1993 and then a year
later and three years later when the Oslo accord was in motion.
PTSD, emotional problems and school performance were
assessed in Palestinian children, 13–15 years of age at time of
follow up. The results show a complex pattern of interaction
between individual differences and various child characteristics
at a time of a high level of political violence and afterwards
when the Intifada ended.
In the midst of the Intifada, politically active children were
reported to show the highest levels of psychological symptoms,
whereas a year and three years later children who were more
active during the Intifada suffered less from various emotional
problems, as reported by their mothers, than passive children.
Also, political activity was found to be a resiliency factor, in
particular when children felt loved and cared for at home.
Moreover the researchers (Qouta et al., 1995) found that
acceptance of the Oslo Accords and a subsequent participation
in the resulting festivities served as a buffer against the negative
impact of the traumatic experiences. The more active the
children were during the Intifada, the more their self-esteem
increased because of the Oslo Accords. In contrast, increased
neuroticism and decreased self-esteem were found only among
those children who did not accept the peace treaty and who
did not participate in the festivities. Finally, results from the
same sample also revealed (Qouta et al., 2001) that, in the
midst of violence, the mental flexibility of children was not
associated with good psychological adjustment; it was found to
moderate long-term negative consequences of traumatic
events and to enhance well being three years later, when the
political events became more peaceful. The fact that Intifadarelated traumas did not increase children’s emotional disorders
three years later, if their perception was characterized by high
flexibility and low rigidity, is indeed a promising finding.
In all, according to the reports of Barber (in 2008a, 2008b)
and the GCMHP group children’s political activity may play
differential mental health roles at times of acute crisis or under
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more favorable conditions. The most promising outcome
reported is that severe psychological symptoms may dissipate
with the decline in acute political violence and danger. These
findings go hand in hand with the stress-evaporation model
(Solomon, 1993; Solomon & Kleinhauz, 1996). Indeed, the
initial Oslo Accords signed between Israel and the PLO positively influenced Palestinian children’s well-being. This was a
positive turning point which concluded the era of the first
Intifada.
One cannot overlook however the large amount of toxicity
among Palestinians in the sense of Garbarino’s (1995) descriptions, especially given the lack of sufficient infrastructures in
the Palestinian territories in all areas of life, along with the
feelings associated with the eruption of the Al Aqsa Intifada.
Contrasted with the first Intifada, described by Carmi Gilon,
a former Israeli chief of Shin Bet (General Security Service),
as an Intifada of hope, the Al Aqsa Intifada was described as
an Intifada of despair.2 The main question of course is whether
daily conditions in the Palestinian territories have cultivated
the ground for what Garbarino refers to as truncated moral
development in which a vendetta mentality begins to predominate, giving rise to the atrocious suicide bombings committed
by some Palestinian youngsters who explode themselves in
buses, restaurants, and other public areas. This topic of suicide
bombers is complex and beyond the scope of this paper. At the
same time it deserves some attention, especially when we
evaluate the mental health infrastructure of Palestinian society.
In his “Staircase to Terrorism: A Psychological Exploration”, Moghaddam (2005a) presents a staircase metaphor
that relies on findings that may promote a better scientific
understanding of terrorism. For the purpose of his discussion,
terrorism is defined as “politically motivated violence, perpetrated by individuals, groups, or state-sponsored agents,
intended to instill feelings of terror and helplessness in a population in order to influence decision making and to change
behavior” (Moghaddam, 2005a, p. 161). Moghaddam evaluates research on terrorism in Islamic societies and Northern
Ireland, among other regions, and concludes that if we really
want to develop effective anti-terrorism strategies we must look
at causes rather than symptoms of terrorism. In this regard,
Moghaddam proposes that “under certain conditions on the
ground floor, where the vast majority of people remain, some
dissatisfied individuals will search on higher floors for solutions
to perceived injustices. If solutions are not found, they are
more likely to climb to the top of the staircase and commit
terrorist acts” (Moghaddam, 2005b, p. 1040). In fact, this is a
five-level staircase that is narrowing from the ground level to
the top level, where the upper level represents the entry into
terrorist life and actions. Accordingly, and this is a rather
critical point, most people will remain on the ground level
despite extensive exposure to adversity and toxicity. Those who
reach the top floor – the level of severe violence and terrorism
– are the minority, and they reach the top most likely because
of despair.
Conceptually this model deals with perceived options, which
for the minority of people are seen as the last resort. If people
feel deprived, humiliated, desperate, and unable to effectively
change their destiny via acceptable measures (i.e. negotiations,
legal protests, and the like), some may begin perceiving
2 “Peace as a security option”, lecture delivered at the Israel Institute of
Technology (Technion), Haifa, Israel, May 23, 2001.
333
extremely violent acts as the only option left. Thus the only way
to minimize the likelihood of such extreme violence is by
providing concrete means that will form alternate perceptions
that are more positive. As Moghaddam concludes (2005b,
p.1040): “the staircase leads to higher and higher floors, and
whether someone remains on a particular floor depends on the
doors and spaces that person imagines to be open to her or
him on that floor.”
In this regard, El Sarraj and Qouta (2005), prominent Palestinian mental health leaders in Gaza, contend that suicide
among young Arabs is extremely rare and even shameful,
because in contrast with what is commonly believed suicide is
perceived as an act that goes against God. Moreover, they
assert that the road to suicide killing is long. However, El Sarraj
and Qouta propose that in the case of Palestinians who never
possessed a state army for their defense, and who have been so
humiliated and desperate, one should not be surprised with the
outcomes. Shalhoub-Kevorkian (2005, 2006) in her description about Palestinian children having to cope with the new
security fence/separation wall brings narratives where children
also explained that their family’s daily survival became more
restricted with the wall. They revealed the way economic,
social, and political hardships further reduced their daily
options for survival, thus raising their levels of anger and frustration, and fueling desires for revenge.
One of the worrisome observations made by El Sarraj and
Qouta (2005) is that an increasing number of Palestinian
children are identifying with “Martyrdom” as a plausible
option. Although the explanations for why and how the
phenomenon of “Martyrdom” evolves are multifaceted, one
plausible reason is an unusually deep emotional expression of
a desire for revenge. Along this line, in a recent GCMHP
research project, 34% of boys from 12–14 years of age said
they considered that the best thing to do in life is to die as a
martyr. El Sarraj and Qouta further maintain that the history
of Palestinians is composed of a series of disasters which took
place in different periods of time, with a serious impact on the
Palestinian psychological state of mind, and they conclude that
“the mood of Palestinian people is still fluctuating between
hope and despair”.
From a human development perspective, it is not surprising
that such profound toxicity might nurture what I refer to as
“seeds of hate”. From a developmental and phenomenological stand point, it makes complete sense to expect it, when a
society endures day-to-day life under such devastating
conditions. In this regard, Shikaki (2006) has proposed in his
Palestinian public opinion research that termination of negotiations when violence erupts leaves the public dependent on
violence as the only means to address grievances and deliver
gains, a process that is fully consistent with Moghaddam’s
analysis of the staircase to terrorism.
To illustrate that such a process is not necessarily Palestinian-specific and that it can take place elsewhere, let us place
the analysis also in an Israeli perspective. One of the declarations made by Ehud Barak, former Prime Minister of Israel
and former Chief of Staff of the Israeli Defense Forces, is
rather powerful. While campaigning for the position of Prime
Minister, in 1998, he said: “If I was a young Palestinian I might
have also joined a terrorist organization . . .” (Verter, 1998).
Moghaddam (2005b) said further that “terrorists are made,
not born. . . . Under certain conditions psychologically normal
adults (italics, A.S-S) can inflict serious and even lethal harm
on others.” Barak, as a leader of a sovereign country, with an
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apparently “good enough” childhood background in a secure
environment in an Israeli kibbutz, allowed himself to say it
loud and clear, from a standpoint of strength. So such
destructive thoughts are apparently a normative part of the
human development repertoire, all the more so when the
reality of others, like that of the Palestinians, is so poisoned
and toxic.
Both Israeli and Palestinian societies have their share in
creating toxic environments as well as being affected by their
respective toxic environments. At the same time it is clear that
improved infrastructures facilitate the delivery of basic human
needs to the broad population the and as such help reduce
toxicity. Israel as a developed country has a much stronger
infrastructure than that of the Palestinian Authority, hence is
less likely to need in reality the “narrowing staircase to terrorism”, although such a perceived option was also in the mind of
one of its peace oriented leaders.
To summarize, Qouta (2004) notes that trauma acquires
special characteristics in the Palestinian context. Despite
reports of various symptoms of PTSD and other behavioralpsychological problems, Palestinian children evince impressive
stamina and strength, and as Qouta and Odeh (2005) note in
a way that “science cannot explain”. Qouta concludes that
their research findings refute the claim that Palestinian parents
push their children to war. Instead, the findings show that
feelings of expressed love and support are core emotions in
most Palestinian parents, apparently serving as important
protective factors. Qouta further asserts that the trauma and
violence have become a challenge for Palestinian children in
Gaza that may not necessarily or always result in negative
outcomes but instead may result in adaptive coping skills.
Conclusions
We have reviewed published as well as unpublished material,
and some of the reported findings are exploratory and therefore should be viewed tentatively with only speculative
conclusions. With such qualifications, it should be noted that
despite the debilitating effects of exposure to chronic political
violence and traumas, various protective factors have been
described. Some children and youth seem to be resilient even
when exposed to adversities, and it is proposed that the
majority is able to cope effectively with the after effects of their
trauma exposure, especially when supported by the family and
by other facilitative factors in the community. Children in war
zones who are competently cared for by their own parents or
familiar adults were reported to suffer far fewer negative effects
than those without such support. Moreover, the community
(e.g. schools, community centers, various religious activities)
can be conceived as a safe haven, especially when there are
opportunities for interaction with people and environments
that are positive for development (Garbarino & Kostelny,
1993a, 1993b).
But there are also limits to the effectiveness of the various
protective factors. Although good parenting can moderate the
negative impact of traumatic experiences, the impact of
violence on parents may create a vicious circle in that their own
capacity to parent might be compromised to some degree.
When parents lose resources, they themselves might become
helpless and ineffective.
On balance, the data from the Israeli and Palestinian cases
seem to be consistent with our findings with Holocaust
survivors and their offspring across three generations (SagiSchwartz et al., 2003) suggesting an outstanding coping and
human endurance. It once again may refute traditional psychological thinking about direct transmission of trauma and its
negative effects, especially when one makes a clear distinction
between trauma that is inflicted from within the family, as is the
case with domestic violence, versus trauma induced by political violence, the source of which comes from outside the family
(Sagi-Schwartz et al., 2003; van IJzendoorn, BakermansKranenburg, & Sagi-Schwartz, 2003). It apparently becomes
more feasible to work through traumas associated with external
sources, or at least to be able to cope adaptively even when the
particular trauma cannot be completely resolved (as is the case
with many Holocaust survivors).
In all, the adverse effects of political violence in war zones
are evident but their extent, depth, and duration vary considerably, depending on the nature of the traumatic events (acute
or chronic, direct or indirect exposure, severity), outcomes
measurement (e.g. PTSD, psychological distress, etc.), and the
presence of protective factors – such as family cohesion, availability of supportive community and social networks and functioning parents – are likely to alleviate negative effects. Risk
factors such as family chaos and malfunctioning parents,
diminished social networks, and destroyed communities and
infrastructures, loss of housing, and uprooting are likely to
have the opposite effect.
Finally, there is a great deal of individual variability in the
capacity of children and adolescents to adapt despite adverse
experiences with political violence. Therefore one may
conclude that despite experiencing an intractable political
conflict, both Palestinian and Israeli children and youth might
have been able to maintain an adequate mental health infrastructure, based on underestimated strength and coping
capacities. Perhaps this is not surprising given recent work in
developmental sciences (Masten, 2001) concluding that
adaptive functioning is normative and not necessarily the
exception to the rule – even under very adverse life circumstances. But further research is certainly begged for in order to
further substantiate this assertion.
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