Psychosocial Problems in Refugee Children Victims of Community Violence in Gaza Strip

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1 Psychosocial Problems in Refugee Children Victims of Community Violence in Gaza Strip Abdelaziz M. Thabet 1,2 *, Sanaa S. Thabet 3 1 Department of Psychiatry, Al Quds University, Child and Family Training and Counselling Center, NGO, Palestine 2 Center for Refugee Studies, York University, Ontario, Canada 3 Child and Family Training and Counselling Center, NGO, Palestine ABSTRACT Aim: The aim of the study was to investigate the prevalence of mental health problems of children as a reaction to community violence and trauma [depression, anxiety, and posttraumatic stress disorder (PTSD)]. Method: For this study 61 children from 2 community centers in one refugee camp in the Gaza Strip. Children administered self-report scales: sociodemographic scale, Gaza Traumatic Events Checklist due to factional fighting, Impact of Events Scale, Children Revised Manifest Anxiety Scale, and Children Depression Inventory. Results: This study showed that children commonly reported traumatic events such as watching pictures of killed and wounded people on TV (90.7%), hearing the shootings and bombardment due to fighting in the streets (85.2%), and hearing arrest or kidnapping of someone or a friend (77.8%). Mean IES was 25.04, mean intrusion was 6.89, mean avoidance was 9.46, and mean arousal was Considering the previous cut off point of 30 and above for IES-13, 29.6% of children were considered as PTSD. The mean CRMAS was Considering the cutoff point of 19 and above, 24.1% of children reported anxiety disorder. Mean depression was Considering the cutoff point of 19 and above, 22.2% of children reported depression. The results showed that there was significant association between total traumatic events reported by children and PTSD and total anxiety. In addition, total anxiety was associated with total PTSD. Clinical implications: The findings showed that community trauma was related to the development of PTSD, anxiety in refugee children in the Gaza Strip. Different levels of programs and interventions had to be described; such program can be put in place after children s basic needs have been met. Keywords: anxiety, community trauma, depression, Gaza Strip, PTSD *Corresponding Author abdelazizt@hotmail.com INTRODUCTION With a population of 1.4 million people, the Gaza Strip is one of the most densely populated areas in the world with 3800 inhabitants/km² and a population growth of four percent per year. Seventy-eight percent of the population within Gaza are refugees and over half of the one million registered refugees are crammed into eight refugee camps managed by the United Nations Relief and Works Agency (UNRWA) [1]. Eighty percent of the population in Gaza falls below the poverty line of US$2 per day (up from 30 percent in 2000) and the unemployment level stands at approximately 50 percent [2, 3]. In addition, people in Gaza have been subject to military occupation, causing significant psychological trauma, particularly for children [4]. Numerous studies have directly linked posttraumatic stress disorder (PTSD) among children to IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 1

2 Psychosocial Problems in Refugee Children Victims Thabet and Thabet the violence and mobility restrictions experienced on a daily basis, including the death and injury of family and friends, damage to property, and the frustration and poverty they sustain through closures, curfews and home confinement. Children have witnessed loved ones being killed or injured; have spent childhood years searching for their belongings in the rubble of destroyed homes and schools, and are living in the reality that no place is a safe place [5,6]. According to a local child activist, Our children are incomplete; they are short on many things. They have had no chance for childhood; they have an energy they cannot express. They have had a hard life. In summary children are paying a heavy and disproportionate price for this conflict many with their lives. In June 2007 fighting broke out between rival Palestinian factions and after days of violent clashes Hamas eventually ousted Fatah and took over the Gaza strip. In reaction to the takeover by Hamas, a nearcomplete closure on its borders has been imposed, causing most sections of the private sector to collapse, resulting in increasing poverty levels amongst the population of the Gaza Strip. Armed clashes have since continued to take place between Palestinian factions with shootings in the street, leaving dozens dead. The distress within households is tangible, with caregivers reporting acute signs of distress among their children and themselves. In this context of extreme volatility, and oftentimes, misery within households and in communities, children say they have little to hope for, and much to fear. With half of the population in the Gaza strip under the age of 18 interventions targeting children and youth are especially important [7]. Palestinian children have few safe places to live, play or learn. Whether they are at home, at school or on the streets, they frequently encounter violence, abuse and exploitation. Life is becoming more violent for children in the Palestinian territory. Signs of distress, such as anxiety, nightmares, disinterest in social interaction and low school achievement, are common among children. Parents, who are also under severe psychological stress, are struggling to cope with their distressed children. Overwhelmed by severe financial hardship and the ongoing conflict with Israel, and are more susceptible to abusing their children. Study Purpose and Objectives The aim of the study was to investigate the prevalence of mental health problems of children as a reaction to community violence and trauma (depression, anxiety, and PTSD). METHOD Participants The sample of this study included a random sample of 61 refugee children, 26 boys (42.6%) and 35 girls (57.4%) attending 2 community centers (Child and Family Training and Counseling center and Women Activities Center) in Beach Refugee Camp, Gaza City. Measures Children were interviewed inside the centers using the following measures: Sociodemogrophic Characteristic Questionnaire This questionnaire includes sex, age, place of residence, and parental information. Gaza Traumatic Events Checklist for Factional Fighting This checklist consists of 20 items covering different types of traumatic events that a child or adolescents may have been exposed to in the particular circumstances of the regional conflict between Fatah and Hamas faction fighting including traumatic events resulting from insecurity and the lawless situation in the Gaza Strip, the last factional fighting and war in the area [8]. This checklist can be IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 2

3 completed by children aged 6 16 ( yes or no ). For the 20-items scale, Cronbachs s alpha was The Children s Revised Impact of Events Scale (CRIES-13) This scale measured symptoms of PTSD. This included all 8 items of the original Impact of Events Scale, as well as 5 items derived from the arousal criteria in the DSM-IV classification (DSM-IV, 1994) [9]. Individual items were rated according to the frequency of their occurrence during the past week (none = 0, rarely = 1, sometimes = 3, a lot = 5) and in relation to a specific traumatic event written at the top of the scale. In this study the revised IES was translated from English to Arabic and back translated. A cut-off score of 30 and above has been found to indicate the likelihood of presence of PTSD [21]. A total score was given, as well as subclass scores for intervention, activation and departure PTSD symptoms. The Revised Children s Manifest Anxiety Scale (RCMAS) (Reynolds and It is a standardized 37-item self-report questionnaire for children of 6 19 years of age [10,11]. It calculates the presence or absence of anxiety-associated symptoms ( yes / no answers) in 28 anxiety items and 9 lie items. A cut-off total score of 19 has been found to predict the presence of anxiety disorder [12]. Child Depression Inventory (CDI) The CDI is a standardized self-report questionnaire of depressive symptomatology [13]. This has been developed for children and young people aged 6 17 years. The CDI includes 27 items, each scored on a 0 2 scale (from not a problem to severe ), for the previous two weeks. The total score ranges between 0 and 54, and a score of 19 has been found to indicate the likelihood of a depressive disorder. The CDI has been adapted for use with Arab children [14]. Study Procedure Data collection was conducted by 3 trained social workers and community mental health workers with assistant research (MPH degree) with previous experiences in data collection in similar projects. They were trained by the first author and project assistance on using questionnaires of the study. Children around the two centers who had been served with their families were invited to participate in the study with their parents. A covering letter will be send to parents explaining the aim of the study and about their right not to participate with their children in study and ask them to sign the letter if they agree to participate with their children in the study. Data were collected in November Statistical Analysis The survey questionnaire was quantitatively analyzed by Statistical Package for the Social Sciences (SPSS win, Ver. 20). Frequency distribution was used in statistical analysis. Independent t- test for the sample and one-way analysis of variance (ANOVA) were used as the main statistical techniques in the study. The t- test was used to determine any statistically significant differences caused by children s gender and trauma, PTSD, anxiety, and depression, whereas ANOVA was employed to determine any statistically significant differences regard to parent's education, place of residence, type of work, number of siblings, and child s age. Pearson correlation test was used to test the correlation between trauma, PTSD, anxiety, and depression. Prediction PTSD in children by traumatic events was tested by series of stepwise multiple linear regression analyses. For qualitative data such as focus group discussion with children analyzed manually by the first author depending in his previous experiences in similar research. The main themes emerged will be listed and discussed. A two-tailed p IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 3

4 Psychosocial Problems in Refugee Children Victims Thabet and Thabet value <.05 was considered statistically significant. RESULTS Sociodemographic Data The sample consisted of 61 children, 26 boys which represented 42.6% and 35 girls which represented 57.4%. The children aged from 8 to 15 years with mean age (SD = 1.97). Palestinian families consisted of large number of children, as 13 (21.3%) had 4 or less children, 18 families (29.5%) had 5 7 children, and 30 families (49.2%) had 8 or more children. Types of Traumatic Events Due to Factional Fighting in the Gaza Strip Our study showed that the most common reported traumatic events by children were: watching pictures of killed and wounded people on TV (90.7%), hearing the shootings and bombardment due to fighting in the streets (85.2%), and hearing arrest or kidnapping of someone or a friend (77.8%). Table 1. Sociodemographic characteristic of the children (N = 54). Sex Items No % Male Female Age The children aged from 8 to 15 years with mean age =11.62 (SD = 1.97) No of siblings 4 and less siblings and more siblings Family monthly income Less than $300 US $ US $ US Above $751 US Table 2. Types of traumatic events due to factional fighting. No % 1. Watching pictures of killed and wounded people on TV Hearing the shootings due to fighting in the streets Hearing arrest or kidnapping of someone or a friend Witnessing neighbors homes exposed to shooting by bullets, rocket, or bombs Being detained at home Hearing killing of a friend Hearing killing of a close relative Witnessing your home exposed to shooting by bullets, rocket, or bombs Deprivation from water or electricity during detention at home Exposed to shooting during the factional fighting while you were crossing the streets Witnessing shooting of a close relative Destroying of your personal belongings Threaten of being killed Exposure to beating, humiliation in the last factional fighting Witnessing shooting of a friend Witnessing killing of a friend Being exposed to shooting during the last shooting and confrontations between factions Witnessing killing of a close relative Threaten of family member of being killed 7 13 IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 4

5 Impact of Events Scale Children Results Type of Posttraumatic Stress Reactions As shown in Table 3, among Palestinian children, the most common reported posttraumatic stress reactions were: try not to think about it (33.3%), try to remove it from his memory (29.6%), and try not talk about it (24.1%). Posttraumatic Distress Disorder Using IES, the mean IES was (SD = 12.43), mean intrusion was 6.89 (SD = 4.63), mean avoidance was 9.46 (SD = 6.22), and mean arousal was 8.69 (SD = 5.61). Considering the previous cut off point of 30 and above for IES-13, 29.6% of children were considered as PTSD. Anxiety Disorder Children reported different symptoms of anxiety. The mean CRMAS was (SD = 6.22). Considering the cutoff point of 19 and above, 24.1% of children reported anxiety disorder. Depression Depression was measured by Children Depression Inventory. The mean CDI was (SD = 5.86). Considering the cutoff point of 19 and above, 22.2% of children reported depression. Table 3. Percentages of posttraumatic stress symptoms according to IES-children. Not at all Rarely Sometimes Often Think about it even when he does not mean to Try to remove it from his memory Have difficulties paying attention or concentrating Have waves of strong feelings about it Startle more easily or feel more nervous than he did before it happened Stay away from reminders of it (e.g. places or situations) Try not talk about it Pictures about it pop into his mind Things keep making him think about it Try not to think about it Get easily irritable Alert and watchful even when there is no obvious need to be Have sleep problems Table 4. Means, prevalence, and SD of trauma, PTSD, anxiety, and depression. N Mean SD N % Traumatic events due to factional fighting PTSD (IES-13) Intrusion Avoidance Arousal Anxiety (CRMAS) Depression (CDI) Relationship Between Trauma, PTSD, Anxiety, and Depression of Children Pearson correlation test was done to find the association between trauma, PTSD, anxiety, and depression of children. The results showed that there was significant association between total traumatic events reported by children and PTSD (r = 0.20, p IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 5

6 Psychosocial Problems in Refugee Children Victims Thabet and Thabet = 0.001) and total anxiety (r = 0.51, p = 0.001). In addition, total anxiety was associated with total PTSD (r = 0.35, p = 0.001). Prediction of PTSD in Children by Traumatic Events In a univariate linear regression analysis, each traumatic event of war was entered as an independent variable in a multiple regression model, with total PTSD scores as the dependent variable, seven events were significantly associated with total PTSD: threaten of being killed (β=0.32, p=0.01), Witnessing you home exposed to shooting by bullets, rocket, or bombs (β=0.29, p=0.01), deprivation from going to toilet and leave the room at home where you were detained (β=0.45, p=0.07), exposed to shooting during the factional fighting while you were crossing the streets (β=0.33, p=0.001), being exposed to shooting during the last shooting and confrontations between factions (β=0.28, p=0.02), watching pictures of killed and wounded people on TV (β=0.29, p=0.01), and witnessing neighbors homes exposed to shooting by bullets, rocket, or bombs (β=0.22, p=0.04), (F = 8.50 p <0.001, R 2 =0.001). Table 5. Pearson correlation test between trauma, PTSD, anxiety, and depression. (1) Trauma 1.00 (2) PTSD.20* (3) Anxiety.51**.35** 1.00 (4) Depression Table 6. Linear regression analysis for prediction of children PTSD by traumatic events. Unstandardized coefficients Standardized coefficients B Std. error Beta T Sig. 95.0% Confidence interval for B Lower Upper bound bound (Constant) Threaten of being killed Witnessing you home exposed to shooting by bullets, rocket, or bombs Deprivation from going to toilet and leave the room at home where you were detained Exposed to shooting during the factional fighting while you were crossing the streets Being exposed to shooting during the last shooting and confrontations between factions Watching pictures of killed and wounded people on TV Witnessing neighbors homes exposed to shooting by bullets, rocket, or bombs Prediction of Anxiety in Children by Traumatic Events In a univariate linear regression analysis, each traumatic event of war was entered as an independent variable in a multiple regression model, with total anxiety scores as the dependent variable, seven events were significantly associated with total anxiety: witnessing shooting of a friend (β=0.35, p=0.001), witnessing your home exposed to shooting by bullets, rocket, or bombs (β=0.33, p=0.001), and deprivation from water or electricity during detention at home (β=0.32, p=0.03) (F = p <0.001, R 2 =0.40). IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 6

7 Table 7. Linear regression analysis for prediction of anxiety by traumatic events. Unstandardized Standardized 95.0% Confidence t Sig. coefficients coefficients interval for B Std. Lower Upper B error bound bound (Constant) Witnessing shooting of a friend Witnessing your home exposed to shooting by bullets, rocket, or bombs Deprivation from water or electricity during detention at home DISCUSSION The study includes a sample of 61 children attending 2 community centers in Beach camp in Gaza. Our study showed that the most common reported traumatic events by children were: watching pictures of killed and wounded people on TV (90.7%), hearing the shootings and bombardment due to fighting in the streets (85.2%), and hearing arrest or kidnapping of someone or a friend (77.8%). Palestinian children reported mean 8.15 traumatic events. This type of traumatic experienced were found in similar studies in the same culture due to similar and other types of political violence [15]. Our results showed that the most common post-traumatic stress reactions reported by children: try not to think about it (33.3%), try to remove it from his memory (29.6%), and try not talk about it (24.1%). These symptoms are similar to previous findings for similar group of children interviewed in Rafah area. This highlight the new coping strategies used by children of avoiding the talk and think about what happen to them (8, 15). However, these findings were different from previous finding in which loss of interest in significant activities, sleep disturbance, avoidance of reminders, intrusive images and sounds, and difficulty concentrating were the most common symptoms [16]. Also, our findings inconsistent with our study of shelling of north of Gaza area in which children reported insomnia, exaggerated startle, and trying to remove memories from their mind [16]. These differences could be the fact that the last factional fighting make children avoid the talking about what had happened between Hamas and Fatah and that the enemy figures was changing from the external enemy to the enemy within the society. This study showed that 29.6% of the children reported above cut point of IES which categorize as possible case of posttraumatic stress reactions. This rate of PTSD was inconsistent with previous study of Orphan children in the Gaza Strip in which 44 children (39.3%) scored within the severe spectrum of the PTSD [17] Our finding was consistent with similar study [18] on 944 children in Gaza, results revealed a high level of PTSD: about one third of the children suffered from a severe level of PTSD symptoms. Our rate of PTSD was less than the study of Thabet et al. (2008) which showed shelling which showed that 71% of children reported PTSD [16]. Our rate of PTSD is less than found in a study of 251 children from 3 summer camps aged 6 16 years. This study showed that children commonly reported traumatic events such as hearing shelling of the area by artillery, hearing the sonic sounds of jetfighters, and seeing images of dead and injured people on TV. Almost sixty percent of children had posttraumatic stress disorder symptoms [6]. Anxiety Symptoms IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 7

8 Psychosocial Problems in Refugee Children Victims Thabet and Thabet Anxiety disorders represent one of the most common forms of child psychopathology. Children total score of anxiety was Considering the cutoff point of 19 and above, 24.1% of children reported anxiety disorder. This result is consistent with our previous study in similar area in which 21% of children were scoring above cut- off point of the scale [19]. Our results were inconsistent the Spence (1998) study of a community sample of 2,052 children, 8 12 years of age [14]. She found lower scores of total anxiety and other subscales. In studies of homeless children and their mothers who were living in Boston home. Our findings were also inconsistent with the findings of studies of children, were that third of the children between the ages of 6 and 18 years had scores on the children. Our results consisted with study of Qouta et al (1997) in study of the effect of home demolition of Palestinian anxiety, they found that children whose homes were demolished showed significantly more psychological symptoms than the children in witness control groups [19]. Age of children was not significantly related to psychological symptoms. This is less than the level of anxiety found in children exposed to continuous shelling in north of Gaza Strip in which 33.9% of children were rated as having anxiety symptoms of likely clinical significance. This is consistent with our previous study of Orphan children in the Gaza Strip in which 32 (28.5%) above the RCMAS (anxiety) cut-off [5]. Our results consistent with study of 251 children from 3 summer camps aged 6 16 years. The study showed 21.9% of children had anxiety disorders [6]. Depression Depression was measured by Children Depression Inventory. The mean CDI was Considering the cutoff point of 19 and above, 22.2% of children reported depression. This is inconsistent with previous study of Orphan children in the Gaza Strip in which 55 (49.0%) reported CDI (depression) scores above the clinical cut-off. Our study level of depression was less that found after the war on 2009 of 251 children from 3 summer camps aged 6 16 were selected which showed that 50.6% of children had depression [20]. CONCLUSION AND RECOMMENDATIONS This qualitative quantitative study of children in one of the refugee camps in the Gaza Strip showed the size of suffering of children due to political, family, community violence and children scored high in depression, anxiety, and PTSD which highlight the need for intervention programmes including the psychosocial situation of the Palestinian children in the Gaza Strip. Also, to call the international organizations in establishing development projects in the area to help children coping with trauma and stress. REFERENCES [1] L. Bassuk, L. Rubin, A.S. Lauriat. Characteristics of sheltered homeless families, Am J Publ Health. 1986; 76: p. [2] E.L. Bassuk, E.A. Gallagher. The impact of homelessness on children, Child Youth Services. 1990; 14: 19 33p. [3] E.L. Bassuk, L. Rosenberg. Psychosocial characteristics of homeless children and children with homes, Pediatrics. 1990; 85: p. [4] A. Dyregrov, W. Yule. Screening measures: the development of the UNICEF screening battery, Paper at The Fourth European Conference on Traumatic Stress. May, 1995, Paris. [5] Thabet, A. A., & Thabet, S. (2017). Coping with trauma among children in Rafah area- Report of study for World Vision, May [6] A.A. Thabet, S. Thabet, P. Vostanis. The relationship between war trauma, IJNeN (2018) 1-9 JournalsPub All Rights Reserved Page 8

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