Risk Factors for PTSD, Anxiety, and Depression Among Adolescents in Gaza

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1 Journal of Traumatic Stress April 2012, 25, Risk Factors for PTSD, Anxiety, and Depression Among Adolescents in Gaza Silje Kolltveit, 1 Ida Ingridsdatter Lange-Nielsen, 1 Abdel Aziz Mousa Thabet, 2 Atle Dyregrov, 3 Ståle Pallesen, 1 Tom Backer Johnsen, 1 and Jon Christian Laberg 1 1 Department of Psychosocial Science, University of Bergen, Bergen, Norway 2 Child and Family Training and Counseling Center, Gaza, Palestine 3 Center for Crisis Psychology, Bergen, Norway The present study examined among adolescents in Gaza the relationship between exposure to war stressors and psychological distress as well as the effects of age, gender, and socioeconomic status. Data were collected from a sample of 139 adolescents 12 to 17 years old. Results showed that adolescents reported elevated levels of intrusion, avoidance, and depression compared to levels in communities not affected by war in the recent past. The proportion scoring within the clinical range of posttraumatic stress disorder (PTSD) was 56.8% compared to 6.3% in peacetime populations, reflecting a Hedges s g of 1.29 (p <.001). Significant risk factors for PTSD were exposure (β =.377, p <.001), female gender (β =.257, p <.001), older age (β =.280, p <.01), and an unemployed father (β =.280, p <.01). Risk factors for anxiety were exposure (β =.304, p <.001), female gender (β =.125, p <.01), and older age (β = 272, p <.01), whereas female gender (β = <.238, p <.001) was the only significant risk factor for depression. The present study suggests large individual differences in how adolescents are affected by war stressors. Although there is ample evidence demonstrating high resiliency in terms of mental health among children exposed to war, a substantial minority of these children suffer from adverse psychological distress (Cairns, 1996). To identify and assist the most vulnerable children, there is a need to gain more knowledge about the relationships between exposure to traumatic events, individual characteristics of the child, and the development of psychological distress. In contrast to the lifetime prevalence of anxiety and affective disorders in peacetime adolescent populations, ranging from 1.3% for posttraumatic stress disorder (PTSD) to 0.8% for generalized anxiety disorder and 9.3% for a single episode of depression (Wittchen, Nelson, & Lachner, 1998), the level of distress is elevated in war-afflicted areas. In a study of Iraqi children and adolescents, 88% scored above the clinical cutoff for The present research project was financially supported by Psychology Beyond Borders and the Children and War Foundation. The authors are grateful to the adolescents who participated in the present study, to the teachers and headmasters of the schools, and to the staff at the Child and Family Training and Counseling Center in Gaza (CFTCC) for assistance and participation. We also appreciate the cooperation of the Education Department of United Nations Relief and Works Agency (UNRWA) and The Ministry of Education in Gaza. Correspondence concerning this article should be addressed to Jon Christian Laberg, Department of Psychosocial Science, University of Bergen, Christiesgate 12, N-5015 Bergen, Norway. jon.laberg@psych.uib.no. Copyright C 2012 International Society for Traumatic Stress Studies. View this article online at wileyonlinelibrary.com DOI: /jts PTSD (Impact of Event Scale [IES]; Horowitz, Wilner, & Alvarez, 1979; cutoff score 17) 1 year after the Gulf War (Dyregrov, Gjestad, & Raundalen, 2002). In a sample of Bosnian refugee children, the proportion scoring above cutoffs on clinical scales measuring PTSD (IES cutoff score 40), depression (Depression Self-Rating Scale for Children [DSRS]; Birleson, 1981; cutoff 17), and unspecific anxiety (Revised Children s Manifest Anxiety Scale [RCMAS]; Reynolds & Richmond, 1978; cutoff score 18) were 28%, 47%, and 23%, respectively (Papageorgiou et al., 2000). Among displaced children in southern Darfur, the prevalence was 75% for PTSD (The Child Post Traumatic Stress Reaction Index; cutoff 41) and 38% for depression (The Children s Depression Inventory; cutoff 61; Morgos, Worden, & Gupta, 2007). In Gaza, the child prevalence of PTSD was 41% (The Child Post Traumatic Stress Reaction Index; cutoff 25; Thabet & Vostanis, 1999) in the 1990s and 70.1% (Children s Revised IES; cutoff score: > 29) in 2008 (Thabet, Tawahina, Sarraj, & Vostanis, 2008). The level of exposure to traumatic events is a significant risk factor for a wide range of mental distress in children and adolescents (Morgos et al., 2007; Pfefferbaum, 1997; Smith, Perrin, Yule, Hacam, & Stuvland, 2002; Thabet et al., 2008). Recently, additional potential risk factors like gender, age, and socioeconomic status (SES) have been suggested to influence the relationship between exposure and distress. In several studies, girls reported higher levels of distress than boys on several outcome measures (Giaconia et al., 1995; Qouta, Punamäki, & Sarraj, 2003; Smith et al., 2002; Thabet & Vostanis, 1998). 164

2 Risk Factors for Trauma Reactions 165 Other studies find no effect of gender (Dyregrov et al., 2002; Dyregrov, Gupta, Gjestad, & Mukanoheil, 2000; Espié etal., 2009), and even the opposite pattern has been reported (Khamis, 2005). It terms of demographic factors, age has been found to be positively related to distress in children and adolescents (Khamis, 2005; Thabet et al., 2008). Some studies reported higher levels of distress in groups of low compared to high SES (Khamis, 2005; Thabet & Vostanis, 1998). Overall, findings of associations between demographic variables, exposure, and levels of distress have not been consistent across studies. In the present study we focus on the role of exposure, gender, age, and SES as potential risk factors regarding the development of posttraumatic stress symptoms, anxiety, and depression among the general adolescent population in Gaza in the Middle East. The Gaza Strip has one of the world s highest population densities (United Nations Relief and Works Agency [UNRWA], 2008) and 44% of the populace is under the age of 14 (Central Intelligence Agency, 2010). Since the creation of Israel in 1948, conflicts have escalated with the first and second Intifada, the blockade of the Gaza Strip, and recently, with the Israeli attack on the Gaza Strip during December 2008 and January So far, few studies have investigated risk factors for psychological maladjustment in adolescents exposed to warfare, and the findings are inconsistent. Thus, the current study may expand our knowledge in this area. We hypothesized (a) that levels of PTSD, general anxiety, and depression would be elevated compared to peacetime levels, (b) distress levels would be positively associated with levels of war exposure, and (c) girls would report higher levels of distress than boys. Further, we expected that age would show a positive relationship with distress, whereas SES would show a negative relationship with distress. Method Participants and Procedure The context of war in Gaza entails several ethical considerations regarding the recruitment for and the execution of studies on mental health (Inter-Agency Standing Committee [IASC], 2007). In accordance with the IASC guidelines (2007), the coordinating and executive responsibility of the project were given to local mental health providers (Child and Family Training and Counseling Center; CFTCC) who arranged further coordination and ethical clearance with UNWRA as well as the Ministry of Education in Gaza. The present study was approved by the Regional Ethical Committee of Western Norway. The sample was drawn randomly from six schools in the refugee beach camp in Gaza. The research team from the CFTCC contacted the Head of the Education Department of UNWRA as well as the Ministry of Education in Gaza for a selection of schools. Four UNRWA schools and two public schools (Ministry of Education) were selected for recruitment. The research team from the CFTCC received a list of all pupils in the target age group from the six schools, and conducted a random selection of participants from this list. Informed consent forms, requiring consent from a parent and the assent of the adolescent, were distributed to 170 families, of which 150 (88.2%) gave their consent. Eleven adolescents did not appear for the assessment. The final sample comprised 139 adolescents aged years (M = 14.52, SD = 1.51) of whom 70 (50.4%) were girls. Data collection took place in the school libraries. Professional psychologists from the CFTCC explained the rationale and procedures of the research project and administered the questionnaires. The questionnaires were completed in group settings, but each child completed her or his questionnaire individually. The questionnaires were marked by a unique identification number and collected immediately after completion. In case of stress reactions to the completion of questionnaires, health personnel were present during the data collection, prepared to assist or refer children to the CFTCC for further follow-up. As the questionnaires were administered 10 months after the end of the latest war (November 2009) the responses reflect postwar data. Measures Arabic versions of all questionnaires were administered. All measures of distress were previously applied in Arabian countries (Panter-Brick, Goodman, Tol, & Eggerman, 2011; Thabet et al., 2008; Thabet & Vostanis 1998) and validated across cultures (Yule, 2002). Information concerning participants age, gender, parents level of education, parents employment status, and estimated family income were provided by the adolescent, of which the latter three were applied as separate indicators of SES. The Gaza Traumatic Check List. The Gaza Traumatic Check List was originally developed by the Gaza Community Mental Health Program (Hein, Qouta, Thabet, & El Sarraj, 1993) to assess level of trauma exposure typical for the Palestinian population in Gaza. This version of the Gaza Traumatic Event Check List, updated after the most recent war, lists 27 events relevant to the Israeli attacks, which the participants indicate having experienced by answering yes or no; for example, Hearing about the killing of a close relative and Hearing the sounds of the fighter planes. The total composite score (0 27) provides an indication of the amount and type of war exposure the respondent has experienced during the war. Revised Child Impact of Event Scale. The Revised Child Impact of Event Scale (CRIES; Smith, Perrin, Dyregrov, & Yule, 2003) is a self-report questionnaire, originally adapted from the (IES Horowitz et al., 1979) for children and youth. The CRIES-13 consists of 13 items related to the three core clusters of symptoms in the PTSD symptomatology: intrusion, avoidance, and arousal. Each item is scored on a 4-point scale with the following response alternatives: 0 = Notatall, 1 = Rarely, 3= Sometimes, and 5 = Often. Symptom severity scores range from The CRIES-13 has been shown to have

3 166 Kolltveit et al. high reliability (Smith et al., 2003). In the present sample the Cronbach s α for the CRIES-13 was.73. Estimation of clinical levels of symptoms used a cutoff score of 17 on the sum of eight items related to intrusion and avoidance (CRIES-8); this has been suggested as efficient for identifying those who might meet criteria for PTSD (Children and War Foundation, 2010; Perrin, Meiser-Stedman, & Smith, 2005). The CRIES-8 was used for classification purposes only, as the score on the CRIES-8 cannot be used to suggest a diagnosis of PTSD. Revised Children s Manifest Anxiety Scale. The Revised Children s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978) is designed to measure symptoms of generalized anxiety in children and youth. The 37 scale items are answered yes or no. Nine items comprise a Lie scale, thus symptom severity scores range from The clinical cutoff score is 18 (Montgomery, 1974). Reliability by Kuder-Richardson- 20 (KR-20) has been found to be high (.85; Lengua & Sandler, 1996). A high correlation (r =.85) has been found between RC- MAS and other instruments measuring trait anxiety (Reynolds, 1980). In the present population, the KR-20 for the RCMAS was.88. Depression Self-Rating Scale for Children. The Depression Self-Rating Scale for Children (DSRS; Birleson, 1981) was developed to assess the degree of depression in children and youth. The scale comprises 18 items, and is scored on a 3-point scale: Mostly, Sometimes, and Never, with eight items reversed. The total score ranges from 0 to 36. The clinical cutoff score for depression has been set to 15 (Birleson, Hudson, Buchanan, & Wolff, 1987). The DSRS has been reported to have good internal consistency (Birleson, 1981). In the current sample, α for the DSRS was.79. Data Analyses Analyses were performed using the R software (R- Development Core Team, 2009). For all measures, when missing data exceeded 25% the person was excluded from the analysis on that specific measure. When missing data represented less than 25%, the median of this participant s score was applied. Descriptive statistics for the central outcome measures were calculated. When the data subsets met all assumptions for parametric statistics, parametrical tests were applied. Nonparametric alternatives were used when appropriate. To compare levels of symptoms in our sample to levels of symptoms in peacetime populations, χ 2 tests or t tests were conducted. The total N appliedintheχ 2 test is the combined sample size of the present sample and the comparative sample. The relationship between the level of symptoms and level of exposure, gender, age, and measures of SES were examined using Kendall rank correlations, as well as t tests and Mann-Whitney U test. The relative effect of exposure and the demographic variables on levels of distress were explored by hierarchical regression models, in which the dependent variables were the measure of distress and exposure, gender, age (measured by two indicator variables with contrasted with and a second contrast); the four SES measures were the independent variables. The possible issue of multicollinearity was addressed by regressing each independent variable on all the other independent variables. None of the resulting R 2 values exceeded.60, and multicollinearity was not considered an issue. The level of significance was set conservatively to p <.01. Results with a p value from will be referred to as borderline significant. This conservative level of significance was set to control experiment-wise alpha inflation. Results Table 1 shows the demographic characteristics, level of exposure, and distress levels in the present sample. The mean total score on the Gaza Traumatic Event Check List was (SD = 5.35) of a maximum score of 27. The most frequently reported events were Watching mutilated bodies on TV (92.1%), Hearing shelling of the area by artillery (91.4%), Hearing sonic sounds of the fighter planes (85.6%), Witnessing the signs of shelling on the ground (78.4%), Witnessing assassination of people by rockets (59.0%), and Hearing killing of a close relative (58.3%). Out of the total sample of 139 adolescents, 79 (56.8%) scored within the clinical range on the CRIES-8 intrusion and avoidance items. This is significantly higher than the 6.3% found to be likely cases of PTSD in a North American peacetime population, χ 2 (1, N = 523) = , p <.001 (Giaconia et al., 1995). An estimated 33 out of 139 adolescents (23.7%) scored above the clinical cutoff on the anxiety scale (RCMAS). The level of anxiety in this sample (M = 12.57, SD = 6.42) was slightly lower than what was found in an American normal population M = 13.84, SD = 5.79), t(376) = 1.97, p =.049 (Reynolds & Richmond, 1978). For depression, 56 out of 136 (41.2%) scored above the recommended clinical cutoff. The mean level of depression in this sample (M = 13.97, SD = 5.90) was significantly higher than what was found in a Russian (M = 11.30, SD = 5.60), t(218) = 3.324, p <.001 (Charman & Perova, 1996), and British normal population (M = 8.60, SD = 4.10), t(259) = 8.468, p <.001 (Charman & Perova, 1996). To explore the relationship between exposure and level of distress, Kendall rank correlations for the exposure scale and each measure of distress were calculated. Exposure was significantly associated with PTSD symptoms as measured by CRIES-13 (τ =.25, p <.001), with adolescents reporting higher levels of exposure tending to report more symptoms. A significant positive relationship was also found between level of exposure and anxiety (τ =.21, p <.001). For depression, however, only a borderline significant relationship was found (τ =.14, p =.026). On all measures of distress, t tests showed a tendency for girls to report higher levels of distress than boys. For PTSD

4 Risk Factors for Trauma Reactions 167 Table 1 Characteristics of the Sample Variable Sample n or M %orsd Gender Female Male Age Family income < $300 per month $ > $ Paternal employment Unemployed Employed Maternal employment Housewife Employed Paternal education Primary school or less Secondary school Higher education Maternal education Primary school or less Secondary school Higher education Exposure (GTECL) PTSD (CRIES-8) Anxiety (RCMAS) Depression (DSRS) Note. N = 139; for depression n = 136. GTECL= Gaza Traumatic Events Check List; CRIES-8 = Children s Revised Impact of Event Scale; RCMAS = Revised Children s Manifest Anxiety Scale; DSRS = Depression Self-Rating Scale. (CRIES-13), the mean score among girls (M = 31.19, SD = 13.07) was higher than among boys (M = 26.68, SD = 10.14), t(129.83) = 2.27, p =.025. The reported level of depression was significantly higher among girls (M = 15.35, SD = 6.08) than among boys (M = 12.55, SD = 5.40; U = 2.59, p =.01). The gender difference on level of anxiety was not significant. Age was not correlated with any of the measures of distress applying Kendall rank correlation. The SES index estimated income was not associated with PTSD or depression symptoms applying Kendall rank correlation. There was a negative borderline significant association, however, between reported income and anxiety symptoms (RC- MAS: τ =.17, p =.016). No significant associations were found between parents education and symptoms of PTSD applying Kendall rank correlation. Lower levels of parental education were associated with higher levels of anxiety among the adolescents (father s education: τ =.19, p <.01; mother s education: τ =.26, p <.001). Further, there was a borderline significant negative relationship between reported parental level of education and depression (father s education: τ =.14, p =.035; mother s education: τ =.15, p =.025). Exploring the association between father s employment status and levels of distress, revealed that children of unemployed fathers reported higher levels of PTSD symptoms (employed fathers: M = 26.23, SD = 11.25; unemployed fathers: M = 32.43, SD = 11.85), t(125.77) = 3.13, p <.01; and for anxiety, those with employed fathers, M = 11.12, SD = 6.09, for those with unemployed fathers, M = 14.43, SD = 6.39 with U = 2.82; p <.01. There was no difference in reported level of depression. Mother s employment status was only related to anxiety with borderline significance; higher among children of unemployed mothers (M = 13.05, SD = 6.43) compared to those with employed mothers (M = 9.86, SD = 5.76), t(29.587) = 2.30, p =.029. To examine the combined effect of total war exposure, gender, age, and indexes of SES on levels of distress, hierarchical regression analyses were conducted (see Table 2). For all measures of distress, war exposure was entered first, gender second, age third, and the separate indicators of SES last as a set. In the final step for the CRIES-13, more exposure, female gender, being older, and father s unemployment were significantly associated with symptoms and accounted for 30% of the variance (p <.001). For the RCMAS the final model explained 27% of the variance (p <.001); higher levels of exposure, female gender, and the age contrast were the only significant predictors. For depression the only significant predictor was gender, accounting for 8% (p <.001) of the variance; girls reported higher levels of depression. The entire model for depression explained 16% of the variance. Discussion The purpose of this study was to determine the risk factors associated with self-reported symptoms of PTSD, anxiety, and depression following war exposure in a sample of adolescents in Gaza. Considering the length and intensity of the conflict in Gaza, it was not surprising to find the level of exposure to war stressors in the present sample to be higher than levels found in peacetime populations (Giaconia et al., 1995). The estimated prevalence of PTSD as measured by CRIES- 13 and depression in the present sample was significantly higher than the prevalence found in peacetime populations (Charman & Perova, 1996; Giaconia et al., 1995). No firm conclusions, however, can be drawn with regard to diagnosis due to a lack of clinical interviews. The elevated levels of PTSD and depression in the present sample are also in line with reported levels of PTSD (Dyregrov et al., 2002; Smith et al., 2002) and depression (Morgos et al., 2007; Papageorgiou et al., 2000) found in populations struck by war. Thus, our data confirm earlier findings indicating that conditions of war increases risk of trauma reactions. Additionally, the lack of any foreseeable solution to the conflict in Gaza, the lack of control, and inability to escape the situation are possible reasons for feelings of hopelessness and helplessness, which may contribute to the development of depressive feelings (Abramson, Alloy, & Metalsky, 1990; Seligman, 1975). Contrary to our hypothesis, the level of anxiety in this sample was comparable to what was found in the American normal

5 168 Kolltveit et al. Table 2 Hierarchical Multiple Regression of Exposure, Gender, Age, and Socioeconomic Status on Levels of Distress CRIES-13 a RCMAS b DSRS c Variable β R 2 β R 2 β R 2 Total exposure (GTECL) Gender d Age e Age Age Socioeconomic status Income Father s education Mother s education Father s employment status f Mother s employment status Note.GTECL = Gaza Traumatic Events Check List; CRIES-13 = Children s Revised Impact of Event Scale; RCMAS = Revised Children s Manifest Anxiety Scale; DSRS = Depression Self-Rating Scale. a R 2 =.30, F(9, 129) = b R 2 =.27, F(9, 129) = c R 2 =.16, F(9, 126) = d Dichotomous variable (female = 0, male =1). e Compared to 12- to 13-year-olds. f Dichotomous variable (unemployed = 0, employed = 1). p <.01. p <.001. population (Reynolds & Richmond, 1978). This finding would indicate that general anxiety is not elevated in this sample and that circumstances of war may have little influence on anxiety per se. It has been suggested that the everyday experience of war stressors among these children may have led to some form of adaption or normalization (Baker & Shalhoub-Kevorkian, 1999; Smith et al., 2002; Ziv & Israel, 1973). It may be, however, that the anxiety scale RCMAS, measuring general anxiety, is not sensitive to specific post trauma reactions (Smith et al., 2002). The level of exposure constituted the best predictor of PTSDsymptoms and anxiety among the adolescents in the presence of the other predictors. This finding confirms previous findings from peacetime populations (Pfefferbaum, 1997) and war (Macksoud & Aber, 1996; Morgos et al., 2007; Smith et al., 2002, Thabet et al., 2008). The association between the quantity of reported traumatic events and level of PTSD symptoms also support the hypothesis of a dose-response relationship between exposure and PTSD as suggested by March (1993) and may also suggest a possibility for a similar relationship between exposure and anxiety in the context of war. Contradicting our prediction as well as other reports from war-exposed populations (Morgos et al., 2007; Smith et al., 2002), the effect of exposure on depression was not significant, explaining only a small part of the variance. Considering the elevated levels of depression in this sample, these results may indicate that depressive symptoms may be closely related to the immediate and ongoing situation and living conditions rather than to exposure to previous traumatic events, as suggested by Kinzie, Sack, Angell, Manson, and Rath, (1986). Still, other factors such as age, gender, and SES did seem to be of importance. In line with several reports from war and peacetime contexts (Giaconia et al., 1995; Qouta et al., 2003; Smith et al., 2002), there was a significant effect of gender on distress, showing higher levels of distress among girls than among boys, despite a higher level of exposure among boys. One possible explanation for both higher exposure and lower level of distress among boys may be a stronger ideological and political commitment, which has been shown to serve as a protective factor in posttrauma reactions in political conflicts (Punamäki, 1996). Active participation in the political conflict may lead to both a higher level of exposure to traumatic events as well as a higher level of ideological and political commitment, which may explain this seemingly higher level of resiliency to war stressors among boys. During the Palestinian intifada of the 1990s, boys were encouraged to participate in the conflict and represented the majority of the active participants. Girls, on the other hand, were discouraged from participation and were more often sheltered at home (Baker & Shalhoub-Kevorkian, 1999). Although age did not contribute significantly in terms of explaining variance in the regression models, the upper age group had elevated levels of PTSD and anxiety. Additional analyses showed that this association could not be explained by a higher level of exposure in the oldest age group. Hence, older adolescents seem to be more vulnerable to anxiety and posttrauma reactions than younger adolescents, a finding in line with previous research (Khamis, 2005; Thabet et al., 2008). The effect of age may be related to varying interpretation of trauma at different developmental stages. Consistent with some previous reports (Morgos et al., 2007), this tendency was not significant for depression. The combination of indicators of SES contributed significantly to the regression models of PTSD and anxiety, but not to

6 Risk Factors for Trauma Reactions 169 the regression model of depression. Only having unemployed fathers, however, was significantly associated with PTSD symptoms. This finding is in line with previous studies reporting higher levels of distress in groups of low compared to high SES (Khamis, 2005; Thabet & Vostanis, 1998). One explanation may be the economic hardship experienced by low-ses families, which may function as a direct source of stress, as well as reducing resources that may buffer impact of trauma on mental health (Desjarlais, Eisenberg, Good, & Kleinman, 1995; Khamis, 2005). None of the individual indicators of SES had a significant effect on anxiety, although there was a borderline significant trend indicating a negative relationship between mother s education and anxiety. Hence, children of unemployed fathers and uneducated mothers may be at high risk for psychological distress. Overall, the indicators of SES are clearly of importance in predicting the level of PTSD and anxiety. In sum, exposure to war stressors was strongly related to PTSD and anxiety. Girls seemed to be more vulnerable to all the posttrauma reactions measured in this study, whereas being older and reporting a general low SES seemed to be an additional risk factor for anxiety and PTSD, and having an unemployed father a third risk factor to PTSD. The limitations of this study include the sample size and measurements. First, the sample size was relatively small, thus generalizations must be drawn with caution. Second, all measurements were self-reports, which are less accurate than clinical assessments. In addition, when relying solely on selfreport the findings may become somewhat inflated by the common method bias (Campbell & Fiske, 1959). The instruments were also limited regarding estimation of diagnosis. Developed for screening purposes, the CRIES-8 (Perrin, Meiser-Stedman, & Smith, 2005) and DSRS (Birleson, Hudson, Buchanan, & Wolff, 1987) estimate a slightly higher prevalence than what would be diagnosed by comprehensive interviews. Without individual clinical assessments, any conclusions about diagnoses must be considered as tentative. Additionally, the instruments applied in this study did not allow for an investigation of other significant factors to mental health in postwar contexts. As highlighted by Miller and Rasmussen (2010), the postwar context entails a higher level of stressful life events and conditions, which may mediate the relationship between exposure and distress as well as have a direct impact on mental health in these populations (Miller & Rasmussen, 2010). Another limitation is that we do not have any specific information concerning how the symptoms reported in the present article are understood and dealt with in the Palestinian context, and what other issues are important to these youths and their coping. Future studies should therefore address this and should also investigate factors within the Palestinian culture that are important for understanding the challenges and future possibilities of its youths. Concerning the strengths of the current study it should be noted that the measures of distress were all standardized, validated, and widely applied instruments. Still, the measures of distress were limited to typical internalizing problems, which are more common among girls. This may represent an obstacle to an accurate and nuanced depiction of the total psychological effect of war on these adolescents, especially in boys. Using self-report for the estimation of SES may be inaccurate, particularly in terms of family income and level of parental education that may be especially difficult for children to report in an accurate manner. Choosing a conservative level of significance, however, reduces the chance of making a Type I error. It should be noted that there are some limitations to the measurement of exposure. Providing only the response alternatives yes or no, the Gaza Traumatic Event Check List prevents detection and assessment of repeated exposure to traumatic events. Thus, it seems to measure diversity of traumatic events rather than the true amount. Further, the list is limited to war-related trauma, precluding assessment of other types of traumatic events that may be critical to the development of PTSD, such as sexual assaults and domestic violence. 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