The impact of political violence on psychosocial functioning of individuals and families: the case of palestinian adolescents

Transcription

1 Child and Adolescent Mental Health Volume 17, No. 1, 2012, pp doi: /j x The impact of political violence on psychosocial functioning of individuals and families: the case of palestinian adolescents Alean Al-Krenawi 1 & John R.Graham 2 1 School of Social Work, Memorial University of Newfoundland, Box St JohnÕs, NI, Canada and Ben-Gurian University of the Negev. alean@bgu.ac.il 2 Faculty of Social Work, University of Calgary, University Drive NW 2500, Alberta T2N 1N4. Canada Background: The impact of political violence on the psychosocial functioning of adolescents and their families was compared for surveyed populations from two regions of Palestine. Method: A randomly-selected sample of 971 adolescents (521 from the West Bank and 450 from the Gaza Strip regions, 42% male/57% female) completed scales measuring traumatic event, post-traumatic stress disorder (PTSD), peer relations, mental health, aggression, and family functioning. Results: (1) West Bank participants reported a significantly higher level of exposure to political violence and significantly more aggression, mental health symptoms, problems in family and social functioning; (2) Participants exposed to greater political violence reported higher levels of depression, hostility, paranoid ideation, and PTSD; (3) Economic status and level of parental education were related to reduced levels of mental health symptoms and greater family functioning; (4) There were gendered differences. Conclusions: The study provides a starting point to begin to compare the experiences and outcomes between Palestinian adolescents in the West Bank and Gaza Strip and a basis for considering implications for service delivery and policy makers concerned with the well being of Palestinian communities. Key Practitioner Message: A study comparing Gaza and West Bank respondents found that the latter had a significantly higher level of exposure to political violence and significantly more aggression, mental health symptoms, problems in family and social functioning Participants exposed to greater political violence reported higher levels of depression, hostility, paranoid ideation, and PTSD Economic status and level of parental education were related to reduced levels of mental health symptoms and greater family functioning Responses to the impact of political violence differed by gender Mental health services should take into account these phenomena when providing clinical services Keywords: Mental health; PTSD political violence; family functioning; aggression adolescent; Palestinian Conditions of prolonged or protracted conflict and political violence have significant adverse effects on all members of society (Gidron, Katz, & Hasenfeld, 2002), including children and youth (Jones & Kafetsios, 2005; Machel, 1996). Extensive research has investigated the psychological reactions of adolescents to war and political violence. Some evidence suggests that the level of exposure to violence and the resulting elevated levels of distress may result in an increased risk to develop psychopathology; including, post-traumatic stress symptomology, mood disorders, externalizing and disruptive behaviours, and somatic symptoms (Al-Krenawi, Graham, & Sehwail, M., 2007; Kinzie et al., 2006; Jones & Kafetsios, 2005; Muldoon, 2004; Qouta, Punamaki, & El Sarraj, 2003; Shaw, 2003;Thabet & Vostanis, 2000, 2004; Tousignant et al., 1999; Macksoud & Aber, 1996; Sack, Clarke, & Him,1993). This is especially the case where exposure to traumatic events is repeated and cumulative, as would be the case in the Palestinian-Israeli conflict (Fazel, Wheeler, & Danesh, 2005; van der Kolk et al., 1996; Herman, 1992). Indeed, the resulting post-traumatic stress disorder (PTSD) and trauma may be chronic as a result of repeated and pervasive exposure to political violence (Van der Kolk, 1987, 1989). Together, the Gaza Strip and the West Bank constitute the Palestinian territories, though they are geographically separated by Israel. The West Bank is inhabited by approximately 2.4 million Palestinians and Gaza Strip by another 1.4 million. The Palestinians have been an occupied people since 1967 and have had 60 yearsõ experience of political unrest and violence since the creation of Israel in The long-standing Israeli Palestinian conflict has escalated since the Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main St, Malden, MA 02148, USA

2 doi: /j x Impact of political violence: Palestinian adolescents 15 beginning of the 21 st Century; first with the El-Aqsa Intifada in 2000 and more recently with the strikes and retaliations in the Gaza Strip. Throughout the escalation, both Palestinian and Israeli youths have been exposed to significant violence and terror, and many have lost their lives or have been seriously injured. As a result and not surprisingly, there are significant impacts on the mental health of those affected. The majority of Palestinian children exposed to traumatic events relating to the conflict are reported to have at least mild intensity PTSD reactions (Thabet & Vostanis, 1999), while a significantly higher percentage of Israeli youths report moderate to severe levels of post-traumatic symptoms (Solomon & Lavi, 2005). Children and adolescents who have experienced conflict also report high levels of depression and anxiety (Mghir et al., 1995; Sagi-Schwartz, 2008; Thabet & Vostanis, 2004). Studies involving children who have been traumatised have found problems with un-modulated aggression, impulse control, attentional and dissociative problems, difficulties negotiating relationships with caregivers and peers (van der Kolk, 2005). Research has also uncovered that, with the presence of conflict and political violence, normal social structures are disrupted, stress and instability increase, and lack of security (Al-Krenawi, Graham & Kanat-Maymon, 2009). Each of these is deleterious to the social and emotional development of adolescents (Al-Krenawi et al., 2007; Giacaman et al., 2007; Punamaki, 2008; Yurtbay, Alyanak & Abali, 2003), and has implications for the collective health status and well-being of their social contexts, including families, peer networks, and communities (Al-Krenawi et al., 2007; Punamaki, 2008). This latter point is significant as it helps to conceptualize the multifaceted impact that exposure to political violence has on all aspects of an adolescentõs life, which directly influenced how the questionnaire for this study was designed. Some writers have compared the effects of exposure to violence for both Israelis and Palestinian youth (Hammack, 2006), and others have focused on the impact of violence for children in specific areas (Khamis, 2000; Baker & Shalhoub-Kevorkian, 1999; Abu Hein et al., 1993; Qouta et al., 2003; Thabet & Vostanis, 2004; Thabet, Abed & Vostanis, 2002; Thabet, Karim & Vostanis, 2006). Missing from the body of literature are contemporary studies on the current experiences of youth and adolescents in the West Bank and the Gaza Strip. The present study aimed to ameliorate the gap in comparative knowledge about youth from the West Bank and the Gaza Strip by focusing on Palestinian youth in both areas; groups who are and will remain vital for conflict resolution and any post-conflict reconstruction within the region. Gaza and the West Bank constitute the sum total of the occupied territories, inhabited by Palestinians. Gaining richer comparative insight into their war time experiences is useful both for developing services for those populations, and for understanding the range and nature of psychiatric symptoms related to war. In particular, we were interested in examining how exposure to political violence predicts psychosocial functioning, PTSD, family functioning, and aggression among adolescents from the West Bank versus those from the Gaza Strip. Research was conducted in 2006 and early 2007, which was a period of relative stability: after the Israeli pull-out from Gaza and before the election of the Hamas government. An analysis of data from the two regions of Palestine the Gaza strip and the West Bank - provides a unique opportunity to consider differential impacts of political violence in the region. In light of the political contexts of that period, we hypothesized that there would be modestly higher levels of exposure to political violence in the West Bank than in Gaza, and that this higher exposure would be predictive of modest results in relation to higher levels of aggression, lower family functioning, lower mental health functioning, higher PTSD, and lower social functioning. Our intention is not to generate theoretical data that may generalise beyond this geographic region. Rather, ours is the first to compare political violence between respondents in Gaza and the West Bank, and our findings therefore have significant implications for policy makers, practitioners, and researchers concerned with the well being of Palestinian communities, as well as the peace process in the region. Method In Gaza and West Bank, the researchers applied to the authoritiesõ respective ministries of education, and in 2006 randomly selected schools from refugee camps, villages, and major cities in both regions to ensure as high a representativeness and heterogeneity as possible vis a vis socioeconomic status and urban versus rural. From those sites we randomly selected 1200 pupils. Of these, 971school-attending male and female adolescents completed the questionnaires, their age ranged from in the West Bank (n = 521) and the Gaza Strip (n = 450) and each student who participated had parental permission. Through the government ministries in Gaza and the West Bank, we had access to a comprehensive list of schools in each territory; and from that list we randomly selected the schools. Likewise, once the schools were randomly selected, we had access from each school to lists of students, from which we randomly selected respondents. The instruments were previously translated into Arabic and back translated to English; and were administered by local graduate students who were fluent in Arabic and familiar with the culture and who were trained by the research team. For cultural reasons, respondents were gender matched with research assistants, data collection took between 30 and 60 minutes, and each survey was conducted in the presence of a research assistant. Research Instruments 1) Background Socio-demographic Questionnaire thirteen items probed the self-reported socioeconomic status of participantsõ families using a Likert scale, and also included questions regarding gender, age, family structure and dwellings. 2) Political violence - a 19 item Traumatic Event Questionnaire probed both personal and family member experiences of and exposure to violent events. A dichotomous scale (yes/no) was used for each item. The internal reliability of the questionnaire was adequate for both West Bank (CronbachÕs alpha = 0.74) and Gaza adolescents (CronbachÕs

3 16 Al-Krenawi & Graham Child Adolesc Ment Health 2012; 17(1): alpha = 0.72). A total score was computed by summing all positive answers (range of scale 0 19), and a high score indicated more exposure to political violence. The instrument was developed by the research team, based on previous research they had carried out in the region (Al-Krenawi, et al., 2009). 3) Mental Health mental health was assessed by the Brief Symptom Inventory (BSI) (Canetti, Shalev & De-Nour-Kaplen, 1994; Derogatis & Spencer, 1982). This measure consists of 53 self-reported items covering nine symptom dimensions of mental functioning: somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety, hostility, panic (phobic anxiety), paranoid ideation, psychotism; and a composite measure of General Severity Index (GSI). The internal reliability of the nine oddscales is adequate (CronbachÕs alpha = ) and the test-retest reliability is satisfactory (r = ). The measure also has a moderate level of validity, which was measured by comparison to the MMPI. Norms and scores among youth population in Israel and United States are available for comparison. In the current study, reliability of the sub-scales was adequate overall and for the GSI specifically (CronbachÕs alpha and 0.94 for the GSI for West Bank adolescents; and for subscales and 0.94 for the GSI for Gaza adolescents). A mean score was computed for each sub-scale, ranging from 0 4, with a higher score indicating more mental health problems (scores of 2.52 and above indicate positive clinical diagnosis). 4) PTSD Post-traumatic Stress Disorder specifically was measured by the PTSD Symptom Scale: The PSS-I (Foa et al., 1993). This scale has 17 items, rating symptoms on a 4-point scale, and is used to assess the changing severity of symptoms in each of the DSM-IV PTSD clusters during the past two weeks. Sub-scale scores are calculated by summing items in each of the PTSD symptom clusters: reexperiencing, avoidance and arousal. The scale has high internal consistency (CronbachÕs alpha = 0.85) and moderate to high correlations with other measures of psychopathology. The PSS-I has high testretest reliability (r = 0.80) and inter-rater reliability (k = 0.91). In the current study, reliability of the total score was calculated as CronbachÕs alpha 0.85 with sub-scales ranging from among the adolescents from the West Bank; for participants from Gaza, CronbachÕs alpha was calculated as 0.84 for total score and for the sub-scales. A mean score was computed for each sub-scale and total scale with results ranging from 1 4, and a higher score indicating more PTSD. 5) Social functioning The Peer Relations Questionnaire is a standard measure for assessing peer group relationships (Hudson, 1982). The questionnaire, consisting of 25 questions suitable for respondents aged 12 and older, has a cut-off point at 35, above which individuals are categorized as having problems. The measure has high internal reliability (CronbachÕs alpha = 0.94) and a low standard measure error (4.44). The peer group measure also has high validity and is able to discriminate between clinical and normal populations. The reliability of the scales among the West Bank and Gaza adolescents in the current study was CronbachÕs alpha 0.87 and 0.86, respectively. The sum score of the instrument was computed (ranging from 0 100), with a higher score indicating more problems in relationships with friends. 6) Aggression This 34-item Aggression Questionnaire (AQ) was developed from a pool of 52 items of the Hostility Inventory (Buss & Perry, 2002). This instrument measures four aspects of aggression: physical aggression, verbal aggression, anger, and hostility. The internal consistency of the AQ is relatively high (CronbachÕs alpha = 0.89). The AQ is a stable instrument with good test-retest correlations of In the current study, reliability among the participants in the West Bank was high, CronbachÕs alpha 0.88 for the total scale and for the sub-scales, and among the participants in Gaza Strip CronbachÕs alpha was 0.86 for the total scale and for the sub-scales. Mean scores were computed for each sub-scale and the total scale. Each scale ranges from 1 5, with a higher score indicating more violent behaviours. 7) Family Functioning - The McMaster Family Assessment Device (FAD) (Epstein, Baldwin, Bishop, 1983; Miller et al., 1985) was utilized for this research. We used only the 12 items that assess the familyõs general functioning. A recent study (Ridenour, Daley & Reich, 1999) found that these 12 items give a satisfactory picture of the familyõs general functioning, and as a result, proposed that there is no need to use all 60 questions. In the current study, the reliability of these 12 items among the participants in the West Bank and the Gaza were CronbachÕs alpha 0.62 and 0.64, respectively. The mean score, ranging from 1 4, was computed for each of the 12 items, with a higher score indicating more problems in family functioning. A comparison of socio-demographic data on participants from the West Bank and Gaza was conducted using Chi-square and t-tests. These two samples were also compared across various dependent measures through a series of t-tests. Pearson correlation coefficients were used to assess the inter-relationship between political violence and the various domains of functioning. Finally, multiple regressions were performed to assess the effect of political violence and nationality on the various domains of functioning while controlling socio-demographic background variables. Data analysis is in four parts. First is a t test and Chi square analysis of demographic, SES, and other differences between the two sample groups. Next is an analysis of the association between respondents in the West Bank/Gaza territories and participant exposure to traumatic events, psychosocial, family functioning, PTSD and aggression. Third, we deploy Pearson correlations to analyse the association between political violence and dependent variables. Finally, we deploy multiple regressions to assess how political violence and ethnicity might predict the dependent variables.

4 doi: /j x Impact of political violence: Palestinian adolescents 17 Findings Results from the group comparison across sociodemographic characteristics, as presented in Table 1, indicate that the West Bank and Gaza Strip participants are equivalent in proportion of males versus females. West Bank participants, however, were almost a year older and indicated they were less religious and had fewer siblings compared to participants from Gaza. In addition, parents of Gaza Strip participants were more educated, and a higher percentage of fathers of West Bank participants were employed. No significant differences were found for parentõs marital status, or for family economic status. Future research, beyond the scope of the present study, could consider controlling for such variables as age. Respondents from Gaza and the West Bank lived in different geographic circumstances; and therefore there could be uncontrolled political, social, or economic facets that may have been present between these two cohorts. A series of independent sample t-tests were conducted in order to examine the differences between West Bank and Gaza Strip participants in their exposure to political violence, mental health, family and Table 1. Socio-demographic variables of the two sample populations West Bank (n = 521) Gaza Strip (n = 450) Significant test Gender Male 42.4% 42.7% v 2 = 0.01 Female 57.6% 57.3% Age, mean (sd) (1.13) (1.31) T = 11.61*** Religiosity Very religious 15.5% 22.5% v 2 = 12.89* Religious 55.9% 54.7% Traditional 22.5% 19.6% Not religious 5.6% 3.2% No. of siblings, 6.07 (2.85) 6.81 (2.69) T = 4.14*** mean (sd) Father s education Less than 8 years 21.9% 11.4% v 2 = 27.24*** 8 9 years 12.5% 11.0% years 11.9% 12.3% 12 years 21.7% 20.0% 13years or more 32.1% 45.3% Mother s education Less than 8 years 31.1% 12.6% v 2 = 57.89*** 8 9 years 14.4% 11.2% years 12.1% 15.9% 12 years 20.9% 26.2% 13years or more 21.5% 34.1% Father s employment status Works 71.2% 54.4% v 2 = 29.26*** Does not work 28.8% 45.6% Mother s employment status Works 13.6% 10.4% v 2 = 2.29 Does not work 86.4% 89.6% Parents family status Married 92.3% 93.6% v 2 = 0.55 Un married 7.7% 6.4% Family s economic status Low 8.8% 10.9% v 2 = 2.67 Average 42.8% 45.6% High 48.4% 43.5% *p <.05; **p <.01; ***p <.001 social functioning, and aggression (reported in Table 2). A rejoinder for the remaining data should be emphasized: because the data is based on large samples, several of the correlations may look significant; but many of the explained variances are often low, therefore we used also CohenÕs ÔD for effect size. West Bank participants reported a significantly higher level of exposure to political violence compared to Gaza Strip participants. West Bank participants also reported higher levels of mental health symptoms, including symptoms on the general severity index (GSI) and somatization, depression, hostility, and paranoid ideation symptoms. Although West Bank participants reported more PTSD symptoms, the results did not reach statistical significance. No significant difference was found across the groupsõ family functioning; however, West Bank participants reported significantly more problems in social functioning and higher levels of aggression on the total aggression questionnaire and all of its sub scales (physical aggression, verbal aggression, anger, hostility). Focusing on CohenÕs D tests, it is clear that differences are small, but in paranoid ideation and physical aggression are closed to medium effect. As presented in Table 3, significant Pearson correlations were found between all the dependent variables in both West Bank and Gaza Strip samples. Participants who reported higher levels of mental health symptoms also reported higher levels of PTSD symptoms, more problems in family and social functioning and increased levels of aggression. These findings support the notion that the dependent variables in the study represent a global measure of mental-social functioning. Furthermore, exposure to political violence was found to be significantly positively correlated with most of the mental-social functioning variables (Table 3). For Gaza Strip participants, exposure to political violence was significantly positively associated with most of the mental health symptoms (except for obsession-compulsion, interpersonal sensitivity and phobic anxiety), with all of the PTSD measures (total score and subscales), with most of the aggression measures (except for verbal aggression), but not significantly correlated with social functioning. In the West Bank sample, exposure to political violence was found to be significantly positively correlated with all of the mental-social functioning variables. Finally, multivariate linear regressions were conducted in order to examine the effect of exposure to political violence and nationality (West Bank versus Gaza Strip) on mental health symptoms, PTSD symptoms, family functioning, social functioning and aggression while controlling for various socio-demographic variables (economic status, parents education, gender and religion) (see Table 4). Exposure to political violence was found to be a significant predictor. Participants who were exposed to greater political violence reported higher levels of most mental health symptoms (except social functioning), including PTSD symptoms (as indicated by the total PTSD score and its subscales), and more problems in family functioning and aggression. Furthermore, as was introduced through unvaried t- tests, West Bank participants, compared to the Gaza Strip participants, reported higher levels of mental health symptoms and showed more problems in

5 18 Al-Krenawi & Graham Child Adolesc Ment Health 2012; 17(1): Table 2. Means, standard deviations and t-tests comparing Palestinians from Gaza Strip and West Bank on the study variables West Bank (n = 521) Gaza Strip (n = 450) Mean SD Mean SD T value Cohen s D Political violence Political violence 9.00 (3.83) 8.28 (3.21) 3.14**.22 Mental health symptoms Somatization 1.19 (.73) 1.08 (.72) 2.41*.15 Obsession-compulsion 1.59 (.75) 1.60 (.71) 0.06 Interpersonal sensitivity 1.41 (.88) 1.39 (.86) 0.32 Depression 1.42 (.88) 1.21 (.81) 3.80***.25 Anxiety 1.40 (.74) 1.32 (.76) 1.79 Hostility 1.53 (.83) 1.33 (.77) 4.03***.25 Phobic anxiety 1.41 (.84) 1.43 (.90) 0.46 Paranoid ideation 1.48 (.81) 1.25 (.74) 4.61***.30 Psychotism 1.37 (.79) 1.29 (.81) 1.41 General Severity Index 1.42 (.63) 1.32 (.59) 2.46*.16 PTSD PTSD 1.92 (.54) 1.87 (.53) 1.32 Re-experiencing 1.91 (.68) 1.89 (.69) 0.44 Avoidance 1.85 (.61) 1.80 (.60) 1.30 Arousal 2.02 (.65) 1.96 (.63) 1.65 Family functioning Family Assessment Device 2.23 (.41) 2.25 (.44) 0.71 Social functioning Index of peer relations (15.92) (15.11) 2.65**.17 Aggression Aggression questionnaire (AQ) 2.42 (.62) 2.26 (.56) 4.25***.27 Physical aggression 2.37 (.89) 2.12 (.79) 4.54***.30 Verbal aggression 2.60 (.78) 2.45 (.70) 3.17**.20 Anger 2.38 (.66) 2.30 (.66) 2.04*.12 Hostility 2.39 (.71) 2.23 (.68) 3.42***.23 *p <.05; **p <.01; ***p <.001 Table 3. Correlation between the research variables: West Bank above the diagonal, Gaza Strip below the diagonal GSI FAD IPR PTSD Aggression Political violence GSI.43***.40***.66***.52***.35*** FAD.33***.30***.35***.21***.17*** IPR.38***.38***.33***.24***.09* PTSD.61***.23***.27***.54***.36*** Aggression.54***.19***.31***.46***.32*** Political violence.13**.03.14**.23***.20*** *p <.05; **p <.01; ***p <.001 GSI General Severity Index; FAD- Family Assessment Device; IPR - Index of Peer Relations; PTSD Post Traumatic Stress Disorder family functioning and increased aggression. Among the socio-demographic variables, economic status was found to be a major predictor; therefore, higher economic status was related to fewer mental health symptoms and PTSD symptoms, fewer problems in family and social functioning, and less hostility. Gender was found to correlate as well; that is, females reported more mental health symptoms (except hostility, paranoid ideation, and psychotism) and PTSD symptoms (except avoidance) as compared to males; while males reported more problems in social functioning, and more aggression, including physical aggression, when compared to females. Finally, parentsõ education was found to have a significant effect on several of the mental health symptoms (somatization, obsession-compulsion, interpersonal sensitivity, depression, anxiety and the general severity index) and family functioning: the higher the level of parental education, the less mental health and family problems). A similar effect was found for religion. The more religious the participant identified as, the less likely he or she was to report on several of the mental health symptoms (depression, anxiety, hostility, paranoid ideation, and GSI), PTSD symptom of arousal, and the entire aggression questionnaire and its sub scales. Discussion Much of our discussion involves the concept of political violence, which we based on a World Health Organization concept and define as a form of collective violence by a civil society or state group towards an individual, group, or community based on the latterõs ethnic, geographic, racial identities (WHO, 2009). Findings are consistent with prior analyses of the impact of conflict and political violence on Palestinian children and youth (Baker, 1990; Barber, 1999; Giacaman et al., 2004; Giacaman et al., 2007; Lavi & Soloman, 2005;

6 doi: /j x Impact of political violence: Palestinian adolescents 19 Table 4. Multivariate linear regression: Political violence and socio demographic variables as predictors of mental-social functioning Political violence Nationality Economic status Parents education Gender Religion R 2 F value Mental health symptoms Somatization 0.24*** 0.04 )0.12*** )0.07* 0.10** ) *** Obsession-compulsion 0.18*** )0.03 )0.13*** )0.07* 0.15*** ) *** Interpersonal sensitivity 0.08* )0.02 )0.13*** )0.11** 0.11** ) *** Depression 0.25*** 0.07* )0.15*** )0.08* 0.13*** )0.10** *** Anxiety 0.22*** 0.00 )0.08* )0.10** 0.17*** )0.11*** *** Hostility 0.22*** 0.09** )0.09** )0.15*** *** Phobic anxiety 0.19*** )0.04 )0.13*** ) *** ) *** Paranoid ideation 0.25*** 0.10** )0.15*** ) )0.13*** *** Psychotism 0.24*** 0.00 )0.10** ) ** ) *** General Severity Index 0.28*** 0.03 )0.15*** )0.08* 0.17*** )0.10** *** PTSD PTSD 0.30*** 0.01 )0.15*** ) * ) *** Re-experiencing 0.29*** 0.00 )0.12*** * *** Avoidance 0.24*** 0.00 )0.13*** ) ) *** Arousal 0.22*** 0.02 )0.11*** ) * )0.07* *** Family Functioning Family Assessment 0.08* )0.06 )0.20*** )0.16*** ) *** Social Functioning Index of peer relations * )0.10** )0.06 )0.10** *** Aggression Aggression questionnaire 0.24*** 0.10** ) )0.11*** )0.12*** *** Physical aggression 0.19*** 0.12*** ) )0.29*** )0.10*** *** Verbal aggression 0.16*** 0.08* ) )0.12*** *** Anger 0.22*** 0.02 )0.01 )0.04 )0.01 )0.09** *** Hostility 0.20*** 0.08* )0.10** ) )0.07* *** *p <.05; **p <.01; ***p <.001 Gender: 0 = male, 1 = female Nationality: 0 = Gaza Strip, 1 = West Bank Nguyen-Gillham et al., 2008; Sagi-Schwartz, 2008; Thabet et al., 2002). However, in contrast with previous studies (i.e. Baker 1990; Barber, 1999), gender, economic status, and level of parental education also had an influence on how adolescent participants were affected by political violence. This later finding was consistent for participants from both geographic locations. Our study uses data gathered prior to the recent escalation of the violence in Gaza. Future research, beyond the scope of the present study, could usefully compare populations before and after the most recent violence in Gaza. For the time being, our research shows that higher level of exposure to political violence and correspondingly higher mental health symptoms and aggression levels in West Bank participants than their Gaza counterparts. West Bank participants may have also experienced more problems in social functioning a correlation that is well established (McNally, 2003; Rummens & Seat, 2004). Consistent with previous research, we found exposure to political violence is a significant predictor of aggression and myriad mental health, family, and social problems (Al-Krenawi et al., 2004, 2007; Baker, 1990; Srour, 2006; Turner et al., 2006). Previous studies show that exposure to violence can disrupt daily life within the family, increase overall family stress, exacerbate any pre-existing familial problems, including domestic violence (Sheidow et al., 2001), and reduced quality of parenting (Khamis, 2005). Palestinian families, especially adult members, are regularly exposed to daily indignities of political checkpoints, constraints on movement, curfews, poor job prospects, continuous threats to personal safety, arrests of family members, humiliations and/or abuse by soldiers and/or settlers, loss of close friends or family members, and the ongoing instability and generalized trauma that has become an established way of life in the region. The continued sense of impotence in the face of these broader forces can be profoundly destabilizing (Al-Krenawi et al., 2002, 2004). It is difficult for parents to provide their children with any real sense of stability when they themselves have none (Srour, 2005). These problems highlight the need for the adoption of a contextual, ecological approach to understanding relationships between conflict or political violence and mental health. The development of psychopathology is not inevitable, but rather reflects contextual factors of the experience social, economic and cultural conditions which have the potential to mediate the relationships and can be addressed by governments and social service agencies (Porter & Haslam, 2005). Our findings also provide insight into relevant factors that may intervene and mediate the relationship between exposure to violence and mental health problems: socioeconomic status, gender, and parental education. The relationship of low socioeconomic status and poor overall health outcomes has been well documented (Harpham, Grant & Rodriguez, 2004; Hemingway et al., 1997). Socioeconomic status (SES) likewise mediates PTSD (Hawajri, 2003; Khamis, 2005). SES reduced our respondentsõ levels of mental health symptoms, including PTSD, and was

7 20 Al-Krenawi & Graham Child Adolesc Ment Health 2012; 17(1): associated with fewer problems in family and social functioning, and less hostility and aggression. Thus government and social service providers might usefully ensure that families can meet basic needs, and obtain physical and social support. Higher parental education is associated with less mental health problems and less problems in family functioning. These results are substantiated in the literature (Graham, Swift & Delaney, 2003; Harpham et al., 2004). Additionally, parental education may play a role in overall family functioning through its influence on parenting style and skills. Family support and guidance through parenting tends to be an important mitigating factor especially for children and adolescents who are exposed to political violence and traumatic experiences (Lie, Sveaass & Eilertsen 2004; Webb, 2004). Results from this study also support the possible mediating role of gender in the development of mental health symptomatology. Adolescent girl respondents report more mental health symptoms, including PTSD, as compared to boys; whereas, adolescent boys report more problems in social functioning and increased aggression (including physical violence), as compared to girls. These gender differences have been corroborated by previous research in the region (Hawajri, 2003; Qouta et al. 2003) and elsewhere (Abdel-Khalek, 1997; Adjukovic, 1998). Within Gaza, research shows that females have higher symptoms of PTSD than males (Hawajri, 2003; Qouta et al., 2003). For boys, socialization may permit increases in aggression more readily, and this may act as a buffer for the development of other mental health symptoms (Kimerling, Ouimette & Wolfe, 2002; Qouta, et al., 2008). Alternately, sex role stereotyping may make girls appear more vulnerable to develop mental health problems because their reactions are more likely to be emotional than physical, or internal rather than external (Kimerling et al., 2002). Conclusion The present study provides a starting point to begin to compare the experiences and outcomes between Palestinian adolescents in the West Bank and Gaza Strip. We find that much of the experiences in both territories are very similar. There are therefore robust possibilities for researchers, policy makers, and practitioners to consider differential and similar levels of resilience and other coping in relation to political violence in the region. Certain factors, such as SES or age, can be mediating variables. The present study has limitations: there may be myriad factors, beyond the scope of the research, that influence the dependent variables. Our research is likewise anchored to specific historic times, and the political situation, particularly in Gaza, has since changed. Nonetheless, the present work provides useful baseline data. And beyond its present scope, additional research that extends the comparative data and expands into areas of resilience and coping would be useful, especially given the recent attacks and retaliations in the Gaza Strip. Acknowledgement This study was supported by the Ford Foundation. The authors have declared that they have no competing or potential conflicts of interest. References Abdel-Khalek, A. (1997). A survey of fears associated with Iraqi aggression among Kuwaiti children and adolescents: A factorial study 5.7 years after the Gulf War. Psychological Reports, 81, Abu Hein, F., Qouta, S., Thabet, A., & El Sarraj, E. (1993). Trauma and mental health of children in Gaza. British Medical Journal, 306, Adjukovic, M. (1998). Displaced adolescents in Croatia: Sources of stress and post traumatic stress reaction. Adolescence, 33, Al-Krenawi, A., Graham., J.R., & Kanat-Mamyon, Y. (2009). Analysis of trauma exposure, symptomatolgy and functioning in Jewsih Israeli and Palestinian adolescents. The British Journal of Psychaitry, 195, Al-Krenawi, A., Graham, J.R., & Sehwail, M. (2002). Bereavement responses among Palestinian widows, daughters, and sons following the Hebron massacre. Omega: Journal of Death and Dying, 44, Al-Krenawi, A., Graham, J.R., & Sehwail, M. (2004). Mental health and violence/trauma in Palestine: Implications for helping professional practice. Journal of Contemporary Family Studies, 35, Al-Krenawi, A., Graham, J.R., & Sehwail, M. (2007). TomorrowÕs players under occupation: An analysis of the association of political violence with psychological functioning and domestic violence among Palestinian youth. American Journal of Orthopsychiatry, 77, Baker, A.M. (1990). The psychological impact of the Intifada on Palestinian children in the occupied West bank and Gaza: An exploratory study. American Journal of Orthopsychiatry, 60, Baker, A., & Shalhoub-Kevorkian, N. (1999). Effects of political and military traumas on children: The Palestinian case. Clinical Psychology Review, 19, Barber, B.K. (1999). Political violence, family relations, and Palestinian youth functioning. Journal of Adolescent Research, 14, Becker, D., Daley, M., Green, M.R., Hendren, R.L, Flaherty, L.T., Gadpaille, W.J., et al. (2003). Trauma and adolescence III: The impact of trauma. Adolescent Psychiatry, 27, Buss, AH, & Perry, M (2002). The aggression questionnaire. Journal of Personality and Social Psychology, 63, Canetti, L, Shalev, AY, & De-Nour-Kaplan, A. (1994). Israeli adolescentsõ norms of the Brief Symptom Inventory (BSI). Israel Journal of Psychiatry and Related Science, 31, Derogatis, L., & Spencer, P. (1982). The brief symptom inventory (BSI): Administration, scoring and procedures, Manual I. Baltimore: Johns Hopkins. Epstein, N.B., Baldwin, L.M., & Bishop, D.S. (1983). The McMaster family assessment device: Reliability and validity. Journal of Marital and Family Therapy, 9, Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. Lancet, 365, Foa, E.B., Riggs, D., Dancu, C.V., & Rothbaum, B.O. (1993). Reliability and validity of a brief instrument for assessing posttraumatic stress disorder. Journal of Traumatic Stress, 6, Giacaman, R., Saab, H., Nguyen-Gillham, V., Abdullah, A., & Naser, G. (2004). Palestinian adolescents coping with trauma. Birzeit: Institute of Community and Public Health, Birzeit University. Giacaman, R., Shannon, H.S., Saab, H., Arya, N., & Boyce, W. (2007). Individual and collective exposure to political violence: Palestinian adolescents coping with conflict. European Journal of Public Health, 17, Gidron, B., Katz, S., & Hasenfeld, Y. (Eds.) (2002). Mobilizing for peace: Peace/conflict resolution in South Africa, Northern

8 doi: /j x Impact of political violence: Palestinian adolescents 21 Ireland and Israel/Palestine. New York: Oxford University Press. Graham, J.R., Swift, K., & Delaney, R. (2003). Canadian social policy: An introduction. Toronto: Prentice Hall. Hammack, P.L. (2006). Identity, conflict, and coexistence: Life stories of Israeli and Palestinian adolescents. Journal of Adolescent Research, 21, Harpham, T., Grant, E., & Rodriguez, C. (2004). Mental health and social capital in Cali, Colombia. Social Science and Medicine., 58, Hawajri, A. (2003). Effectiveness of a suggested counselling program to alleviate trauma among the students of basic stage in Gaza Governorate. Unpublished M.A. Dissertation, Islamic University, Gaza, Palestine. Hemingway, H., Nicholson, A., Stafford, M., Roberts, R., & Marmot, M. (1997). The impact of socioeconomic status on health functioning as assessed by the SF-36 questionnaire: The Whitehall II Study. American Journal of Public Health, 87, Herman, J.L. (1992). Trauma and recovery. New York, USA: Basic. Hudson, W.W. (1982). The Clinical Measurement Package: A Field Manual. Chicago: Dorsey Press. Jones, L., & Kafetsios, K. (2005). Exposure to political violence and psychological well-being in Bosnian adolescents: A mixed method approach. Clinical Child Psychology and Psychiatry, 10, Khamis, V. (2000). Child psychological maltreatment in Palestinian families. Child Abuse & Neglect, 24, Khamis, V. (2005). Posttraumatic stress disorder among school age Palestinians children. Child Abuse & Neglect, 29, Kimerling, R., Ouimette, P., & Wolfe, J. (Eds) (2002). Gender and PTSD. New York: Guilford. Kinzie, J.D., Cheng, K., Tsai, J., & Riley, C. (2006). Traumatized refugee children: The case for individualized diagnosis and treatment. Journal of Nervous and Mental Disease, 194, Lavi, T., & Solomon, Z. (2005). Palestinian youth of the Intifada: PTSD and future orientation. Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), Lie, B., Sveaass, N., & Eilertsen, D. (2004). Family, activity, and stress reactions in exile. Community, Work & Family, 7, McNally, R. (2003). Remembering trauma. USA: Harvard University Press. Machel, G. (1996). The impact of armed conflict on children. United Nations Department for Policy Coordination and Sustainable Development. A/51/306,1996. Macksoud, M.S., & Aber, J.L. (1996). The war experience and psychosocial development of children in Lebanon. Child Development, 67, Mghir, R., Freed, W., Raskin, A., & Wayne, K. (1995). Depression and posttraumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. Journal of Nervous and Mental Disease, 183, Miller, I.W., Epstein, N.B., Bishop, D.S., & Keitner, G.I. (1985). The McMaster Family Assessment Devise: Reliability and validity. Journal of Marital and Family Therapy, 11, Muldoon, O.T. (2004). Children of the Troubles: The Impact of political violence in Northern Ireland. Journal of Social Issues, 60, Nguyen-Gillham, V., Giacaman, R., Naser, G., & Boyce, W. (2008). Normalising the abnormal: Palestinian youth and the contradictions of resilience in protracted conflict. Health & Social Care in the Community, 16(3), Porter, M., & Haslam, N. (2005). Predisplacement and postdisplacement factors associated with mental health of refugees and internally displaced persons. Journal of the American Medical Association, 294(5), Punamaki, R.L. (2008). Developmental challenges in military conflict The case of Palestinian children. In M.E. Garralda & J.P. Raynaud (Eds), Culture and conflict in child and adolescent mental health (pp. 3 32). USA: Jason Aronson. Qouta, S., Punamaki, R. L., & El Sarraj, E. (2003). Prevalence and determinants of PTSD among Palestinian children exposed to military violence. European Child and Adolescent Psychiatry, 12, Qouta, S., Punamaki, R. L., Miller, T., & El Sarraj, E. (2008). Does war beget child aggression? Military violence, gender, age and aggressive behavior in two Palestinian samples. Aggressive Behavior, 34, Ridenour, T.A., Daley, J., & Reich, W. (1999). Factor Analyses of the Family Assessment Device. Family Process, 38, Rummens, J., & Seat, R. (2004). Assessing the impact of the Kosovo conflict on the mental health and well-being of newcomer Serbian children and youth in the greater Toronto Area. Journal of the American Academy of Child and Adolescent Psychiatry, 30, Sack, W.H., Clarke, G., & Him, C. (1993). A six-year follow-up of Cambodian traumatized youth and children. Journal of American Academy of Child and Adolescent Psychiatry, 32, Sagi-Schwartz, A. (2008). The well-being of children living in chronic war zones: The Palestinian-Israeli case. International Journal of Behavioral Development, 32, Shaw, J.A. (2003). Children exposed to war/terrorism. Clinical Child and Family Psychology Review, 6, Sheidow, A.J., Gorman-Smith, D., Tolan, P.H., & Henry, D.B. (2001). Family and community characteristics: Risk factors for violence exposure in inner-city youth. Journal of Community Psychology, 29, Solomon, Z., & Lavi, T. (2005). Israeli youth in the second Intifada: PTSD and future orientation. Journal of the American Academy of Child and Adolescent Psychiatry, 44, Srour, R.W. (2005). Children living under a multi traumatic environment. Israel Journal of Psychiatry, 42, Srour, R. W. (2006). Communal and familial war-related stress factors: The case of the Palestinian child. Journal of Loss and Trauma, 11, Thabet, A., Abed, Y., & Vostanis, P. (2002). Emotional problems in Palestinian children living in a war zone: A crosssectional study. The Lancet, 359, Thabet, A., Karim, K., & Vostanis, P. (2006). Trauma exposure in pre-school children in a war zone. British Journal of Psychiatry, 188, Thabet, A., & Vostanis, P. (1999). Posttraumatic stress reactions in children of war. Psychiatric Bulletin, 23(5), Thabet, A., & Vostanis, P. (2000). Post traumatic stress disorder reactions in children of war: A longitudinal study. Child Abuse and Neglect, 24, Thabet, A., & Vostanis, P. (2004). Comorbidity of PTSD and depression among refugee children during war conflict. Journal of Child Psychology and Psychiatry, 45, Tousignant, M., Habimana, E., Biron, C., Malo, C., Sidoli LeBlanc, E., & Bendris, N. (1999). The Quebec adolescent refugee project: Psychopathology and family variables in a sample from 35 nations. Journal of the American Academy of Child & Adolescent Psychiatry, 38, Turner, H.A., Finklehor, D., & Ormrod, R. (2006). The effect of lifetime victimization on the mental health of children and adolescents. Social Science and Medicine, 62, van der Kolk, B. A. (2005). Developmental trauma disorder. Psychiatric Annals, 35, van der Kolk, B.A., Roth, S., Pelcovitz, D., Sunday, S., & Spinazzola, J. (2005). Disorders of extreme stress: The empirical foundation of complex adaptation to trauma. Journal of Traumatic Stress, 18,

9 22 Al-Krenawi & Graham Child Adolesc Ment Health 2012; 17(1): van der Kolk, B. A. (1989). The compulsion to repeat the trauma: Re-enactment, revictimization, and masochism. Psychiatric Clinics of North America, 12, van der Kolk, B. A. (1987). Psychological trauma. Arlington, VA: American Pscyhological Publishing. Webb, N. (Ed.) (2004). Mass trauma and violence: Helping families and children cope. New York: Guilford. World Health Organization. Definition and typology of violence. Available from: approach/definition/en/index.html [Last accessed 30 December 2009]. Yurtbay, T., Alyanak, B., Abali, O., Kaynak, N., & Durukan, M. (2003). The psychological effects of forced emigration on Muslim Albanian children and adolescents. Community Mental Health Journal, 39, Accepted for publication: 27 September 2010 Published online: 13 June 2011