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Traumatized childhood: growing up under the shadow of a conflict

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Itzhak Levav


Pat-Horenczyk. R.1,2, Brom, D. 1,2 , Lerner, N. 1
1 Israel Center for the Treatment of Psychotrauma, Herzog Hospital, Jerusalem, Israel
2 School of Social Work and Social Welfare, Hebrew University of Jerusalem, Israel
Levav, I.3
3 Department of Community Mental Health, Haifa University.

From individuals and families to entire communities and collective cultures, the trauma of armed conflicts has a long-lasting impact. The conflict between Israelis and Palestinians dates back almost 100 years and is a protracted conflict as defined by the persistence over a long period of time despite a series of interventions that typically results in unacceptable settlements (Putnam & Wondolleck, 2003). "Violence ... usually involves a wide range of aggressive acts, beginning with destructions of properties, refugees' movement, imprisonments, expulsions, through killings and injuries as part of the "normal" violent encounters between the rivals.... as the events become harsher and more severe, they cause very severe reactions. Exposure to such violent events has detrimental effects on human beings." (Lavi and Bar Tal, in press).
This article provides a short bird's eye view of studies that were conducted on the emotional impact of the conflict on children and adolescents. This paper is heavily based on work done by the Israel Center for the Treatment of Psychotrauma, partly in collaboration with Palestinian colleagues. In this non-exhaustive review, we will succinctly cover contextual dimensions of the conflict under which children grow up, as well as addressing the following questions: (a) What are the long-term consequences of living under ongoing threat of political violence and the toll of protracted "survival mode"? (b) What is the prevalence of post-traumatic stress in children and adolescents who were directly or indirectly affected on both sides of the Israeli-Palestinian conflict? (c) Does the psychological impact differ according to the developmental stage in which the child is affected? (d) What is the role of parenting in mitigating the reaction to trauma? (e) What do we know about comprehensive school-based interventions for children living under these violent circumstances? We conclude with brief recommendations while the conflict lasts for best practice interventions for school and communities based on the evidence presented throughout the article.

The Israeli - Palestinian conflict and its context
The conflict between Israelis and Palestinians has created different sources and forms of traumatization. Since 1967, following the Six Day War, the situation of Palestinians and Israelis has certainly not been similar or comparable, but both sides have sustained losses, injury, emergency situations and severe anxiety-provoking events. On the one hand, there is a population living under long-term occupation, military incursions, large scale incarceration of suspects and a myriad of roadblocks that make transit within the Palestinian territories quite difficult. On the other hand, the population of Israel has lived with wars with the neighboring countries, suicide bombings, frequent missile attacks and compulsory military service.
As in most or all conflicts, the psychological impact of violence seems to be strongly colored by the meanings assigned to it as well as by its nature, whether religious-inspired or human-dependent. For example, with regard to individuals and families whose approach to the conflict is entirely impregnated by religious beliefs, the adverse effects are challenges that could be withstood, since they are conceptualized as unavoidable consequences on the way to overcome the infidel adversary. At times, the adverse consequences are even expected to be rewarded by divine powers. In contrast, for those who regard the conflict as human-dependent (e.g., based on territorial dispute) the violence that hits the individual may shatter the trust in the leaders and as time goes by, cause psychosocial fatigue. Eventually, it may lead individuals to adopt a different conceptualization of the conflict and the course of action that needs to be followed. This outcome is particularly present in those that have been bereaved on account of violence, and as a result they tend to reorganize their internal set of values with regard to the conflict. Ultimately, they may even adopt a new role, such as becoming advocates of peace, and to assume a new perception of themselves and of the other.
Briefly stated, the understanding of the psychopathological impact of conflict must take into account the socio-political-ideological-religious climate of the protracted conflict to explain the heightened or reduced reactions to the violence over the years. The psychological impact of the ongoing conflict on both Israelis and Palestinians has been the subject of considerable research. A large number of scientific articles have been written by Palestinian and Israeli mental health professionals, either product of solo or collaborative research. The concerns of mental health professionals with regard to the psychological effects of the conflict do not recognize geographical borders. As the overall result of research indicates, children and adolescents of both sides must cope with serious adverse psychological consequences. Indeed, nobody is immune to violence of any type, although the magnitude and characteristics of the reaction may differ, as will be noted later.

Cumulative trauma and survival mode
Though there remains a debate about whether there is an accumulated impact of stress, or whether people habituate to its impact, recent research provides supportive evidence for the former (Pat-Horenczyk et al, 2013). This outcome, referred to as "allostatic load", describes the cumulative physiological toll exacted on the individual while living continuously under stressful or traumatic circumstances (more simply, the wear and tear on the body). In times of crisis, it is natural for the individual to enter into "survival mode". This state, comprises of behaviors that help the person to keep alert, avoid risks, and to focus efforts on staying safe and responding quickly and efficiently to threat, It remains adaptive only in the face of immediate danger. The challenge after extreme events is to re-adapt to safety conditions (Brom, 2014), and avoid a chronic hyper-arousal state that ultimately may cause exhaustion and depletion of internal and external resources.
Further distinction was made by Pat-Horenczyk et al. (2013) between single and continuous exposure to violence specifically that of missile attacks. This 2013 Israeli study compared a sample of 85 preschool children and mothers with ongoing and recurring exposure to missile and rocket attacks ("continuous sample") to a sample of 177 children and mothers with trauma exposure from a recent time-limited war ("past sample"). Results indicated the severe consequences of facing ongoing traumatic stress. Children under continuous exposure had more posttraumatic distress and higher behavior problem scores compared with those in the past exposure sample. Additionally, 45% of the children in the continuous exposure sample were diagnosed with PTSD, compared with 15% in the past exposure sample, supporting the allostatic load hypothesis whereby cumulative stress exacts a heavier toll. In parallel, 46% of mothers in the continuous exposure sample reported posttraumatic distress on a clinical level, compared with 21% in the past exposure sample. The psychological toll of ongoing conflict on children and their caretakers has lead researchers to examine many factors which may either increase, or mitigate reactions resulting from traumatic exposure.

Risks and protective factors for posttraumatic stress among children and adolescents Prevalence of posttraumatic distress
Indications of elevated levels of PTSD among both Israeli and Palestinian school age children led researchers to begin to assess both risk and protective factors associated with traumatic stress in children. A number of studies that used school-based screenings to assess the prevalence of Post Traumatic Stress Disorder (PTSD) among Israeli children found that the rates of full PTSD ranged from 5% to 27% (Pat-Horenczyk, Abramovitz et al, 2007, Solomon & Lavi, 2005), significantly above average for children not exposed to the conflict. Among Palestinian children, prevalence rates of up to one third of children in a cross sectional sample were found to exhibit at least partial symptoms of PTSD (Pat-Horenczyk , Qasrawi et al, 2009). Punamaki and colleagues (2011) tested the prevalence of resilience in the presence of military violence in a Palestinian community sample of 640 children and adolescents, their parents and teachers. In this study there were equal shares of resilient (21%; high level of trauma and low level of disorders) and traumatized (23%; high level of trauma and high level of disorders) children. Importantly, the resilient children and adolescents were characterized by good parental mental health.
Risk factors
Exposure to traumatic events has been the most researched risk factor for post-traumatic stress. Both Israeli and the Palestinian contexts present a combination of trauma exposures that, depending on the affected side, include armed military operations, terrorist attacks and missile attacks, among others. All those have the potential to change daily routine, such as going to kindergarten or school or playing outdoors. In addition, children and caregivers acquire a constant state of vigilance and awareness, including the habit of looking for safe locations under conditions of threat. Those, coupled with "near miss" scenarios that go beyond direct exposure, such as being at the location of an armed attack few moments before it occurred, or knowing someone who was injured or killed, have the capacity to elicit posttraumatic symptoms (Pat-Horenczyk, Abramovitz et al, 2007). Furthermore, a study has shown that adolescents who suffer from post-traumatic symptoms reported more risk-taking behaviors than adolescents that were equally exposed to traumatic events but did not develop PTSD (Pat-Horenczyk, Peled et al, 2007).
A growing awareness that young children are affected by direct exposure to violence stimulated new research on previously overlooked toddlers and pre-school aged children. Children are at higher risk for suffering from post-traumatic symptoms and functional impairment due to the combined effects of direct trauma exposure and the deleterious effect of trauma on their immediate ecological system, including family, community and the wider society (Pat-Horenczyk, Qasrawi, et al., 2009). Indeed, evidence shows that young children are especially vulnerable to both direct exposure and also harmed by indirect exposure, such as television media. Studies showed that young children who watched five or more minutes of terrorism-related content on a regular basis were at an increased risk for externalizing behaviors, sleep problems, emotional reactivity, aggression, and oppositional defiant behaviors (Wang et al 2006).
Gender differences were found in the profile of posttraumatic symptoms; while girls complained more on subjective distress and reported more severe post traumatic symptoms, boys manifested more functional impairment, in family and social domains, as well as higher levels of suicidal ideation. Additionally, higher levels of exposure resulted in increased post-traumatic stress in girls, while in boys there was no such a dose-effect (Pat-Horenczyk , Abramovitz et al, 2007).
Protective factors
As concluded by Masten (2001), a majority of children show resilient responses, which she termed "ordinary magic". The concept of resilience has stimulated a burgeoning body of research on a variety of protective factors that may mitigate the impact of trauma on children.
The inclusion of protective factors in addition to risk factors in screening methods for posttraumatic distress broadened the understanding of post-trauma adaptation trajectories, and improved the clinical triage (that is, the determination of the priority of therapeutic interventions based on the severity of the condition) for school-based intervention. Among the protective factors studied are coping strategies, self efficacy, social support, flexibility and help-seeking (Pat-Horenczyk, Rabinowitz, et al., 2009, 2013, Schiff et al, 2010, 2012).
In light of the growing awareness of the centrality of protective factors for identifying affected children and adolescents, a new model based on protective factors was designed to aid in the triage of students who require specialized care. This alternative screening model utilizes protective factors, rather than pathology, to assess symptom severity. Based on the assessment of three positive characteristics, including self-efficacy, coping strategies and flexibility, the model correctly classified 84% of adolescents presenting with posttraumatic distress. The advantage of the strength-based approach is that this kind of screening and triage may lessen stigmas and increase cooperation (Pat-Horenczyk et al, 2013).
Beyond the variables used in screening, researchers began looking for other protective factors which could help moderate a child's reactions to traumatic events, especially those which affect broader aspects of behavior and attitude. One such variable was as the ability to maintain routine at home and school despite continuous exposure to violence (Pat-Horenczyk, Doppelt & Schiff, 2006). These authors found that not only did keeping daily routine serve as a protective factor, but a loss of routine was a significant predictor for higher levels of post-traumatic stress and functional impairment, even after controlling for level of exposure to violence, age, and gender.

Impact of ongoing conflict on families
No one is an island unto him/herself, but it is the children that are most dependent on their caregivers, usually the mother, for love, nourishment and shelter. Indeed, the mother-child dyad constitutes an almost closed system. Theory has long pointed to the crucial role of parents and caretakers as a protective shield for children. Mother's coping patterns after traumatic exposure have been found crucial in helping the child adjust and cope after trauma (Pat-Horenczyk et al, 2012). The construct of relational PTSD, measured by the co-occurrence of posttraumatic distress in both mother and child (Scheeringa & Zeanah, 2001), defines the direction of influence such that the symptoms of the mother exacerbate those of the child. This influence is especially strong in early childhood, when the child requires external cues for their own learning and regulation (Lieberman, 2011; Pat-Horenczyk et al, 2012, 2013). The weakening of parenting abilities in the shadow of post-traumatic stress has been shown to take the largest toll on the mother-child relationship. The traumatic exposure overloads the mother's ability to parent (she is unable to soothe, comfort, and provide co-regulation of fear) and hampers her ability to create a sense of safety for her child.
Feldman and Vengrober (2011) studied a group of 148 toddlers living near the Gaza Strip who were exposed to missile attacks and 84 unexposed children. They identified PTSD in 38% of children exposed to violence. These young children also exhibited substantial developmental regression, nonverbal representation of trauma in play, frequent crying, mood shifts, and social withdrawal. Furthermore, the mothers of those children with PTSD reported the highest depression, anxiety, and posttraumatic symptoms, and the lowest level of social support. Similar finding were reported by Pat-Horenczyk et al. (2012) in a study of mothers and their young children living under continuous exposure to missile attacks. Their findings indicated that 33% of the children and 28% of the mothers met the criteria for PTSD. Additionally, the results showed that a high level of maternal distress approximately doubles the child's chances of having a behavioral problem in the clinical range. More than 34% of the children of mothers with full or partial PTSD had a clinical level of internalizing problems, compared to 18% of the children of mothers with low-distress. Similarly, 19% of the children of mothers with severe post-traumatic reactions showed clinical-level externalizing problems, compared to 8% of the children of mothers with low distress. Another study by Kaufman-Shiriqui et al (2013), among preschool children and their mothers who had been exposed to missile attacks fired from Gaza, reported that 21% of children were identified with full-fledged PTSD. They also reported on significantly higher rates of psychosomatic reactions to trauma, such as constipation, diarrhea and headaches in the children with PTSD as compared to children who did not show substantial posttraumatic symptoms.
New research provides evidence that the specific pathway of transmission of relational trauma lies in the ability of the mother to regulate and co-regulate emotion with their child. One study found that relational trauma was more prevalent in mothers and young children exposed to continuous missile attacks than in a sample that had been exposed to a time-limited war (Pat-Horenczyk et al, 2013). The level of PTSD was higher in both mothers and children exposed to continuous threat. Moreover, 58% of the mothers with PTSD under continual exposure had children who also suffered from PTSD, whereas only 17% of the mothers with PTSD exposed to a time-limited war had children with PTSD.
Similar results were found by Palestinian researchers who examined the relationship between ongoing war experiences, PTSD and anxiety symptoms in older children, accounting for their parents' equivalent mental health responses. The study was conducted in the Gaza Strip among 100 families living in areas exposed to shelling. Families with two children aged from 9 to 18 years were included. A total number of 200 parents (equally divided by mothers and fathers) and 197 children of 9-18 years of age participated in the study. Families were selected randomly from two villages, one camp, and one city. Both children and parents reported high exposure to stressful events, particularly acts of violence by the Israeli army and witnessing traumatic events on TV. Children reported different reactions e.g.: insomnia (41%), exaggerated startle reactions (39%), and trying to remove memories from their mind (39%). Seventy percent were identified with PTSD. As in the Israeli studies, parents' emotional responses were significantly associated with children's PTSD and anxiety symptoms. Therefore, the researchers concluded that interventions should target families rather than exclusively the young (Thabet et al, 2008)

Interventions for children in the community
Observation of the clinical needs of children suffering from posttraumatic distress and functional impairment led to the development of effective ways to identify and treat affected children, as well as to provide interventions in order to build resilience and prevent distress. The international community had already begun utilizing school-based screenings for post-traumatic stress in children following natural and human-made disasters (Pfefferbaum & Shaw, 2013). These studies found that up to two-thirds of children with severe post traumatic symptoms were not identified by parents or teachers as requiring treatment, and thus were not being referred for help (Hoven et al., 2004). Following the international example, several Israeli studies began employing school based screening to assess the impact of terrorism, during the Al Aqsa Intifada starting in 2000, on post-traumatic symptoms, functional impairment, and related distress such as depression and somatic complaints ( Pat-Horenczyk, Abramovitz et al, 2007, Solomon & Lavi, 2005).
The ability of parents, families, and communities to provide an environment which can keep secure optimal developmental trajectory is impaired by the trauma of armed conflict. Research on Israeli and Palestinian children living under threat of violence stimulated the design of appropriate interventions. In societies where a large percentage of children are at risk for post- traumatic reactions, it is crucial to provide care which is accessible, effective and sustainable. Though individual cases may justify a need for one-on-one clinical intervention, this is not feasible in a population with a vast need for services and/or with qualified insufficient human resources. By partnering with teachers and school systems, a wider net can be cast to provide both resilience building and post disaster responses. School based interventions have been found to be less stigmatizing, more economical and practical to implement, and are effective in screening and treatment of post-traumatic children (Berger 2007, Brom , Pat-Horenczyk, & Baum, 2011, Pat-Horenczyk et al., 2011). Empowering teachers to help their students has been shown to build resilience and provide a sustainable platform for post-trauma services (Baum et al. 2013).
Given the continuous violence on both sides of the conflict, it is imperative to design comprehensive intervention models beyond the scope of schools in preparing for and responding to traumatic events. Creating a synergy between families, educational institutions, the welfare system and the mental health sector can reduce the gaps in services that tend to develop by systems that tend to work separately. Within the continuity of care, systems should incorporate both community and clinical principles, and recognize the importance of reaching out and supporting healthy post-traumatic trajectories, and of treating those who are suffering from post-traumatic psychopathology (Brom et al, in press). . A fluid and flexible approach involving evidence-based interventions should serve to educate, empower, and engage those involved in the care of children exposed to the realities of war, terrorism and political violence (Kletter et al, 2013).

Conclusions and recommendations
There is strong evidence for the pervasive toll that children, families and communities pay for living in the midst of ongoing armed violence. This brief review provides evidence for the greater vulnerability of children, and especially also of preschoolers. Prolonged trauma and living under continual threat has debilitating effects on the abilities of parents to provide safe bonding, co-regulation of fear responses and secure and optimal development of their children. Even though most of the research focuses on post-traumatic symptoms, there is a growing understanding that the impact of trauma goes beyond symptoms of emotional distress and can encompass changes in attitudes, moral judgment and aggressive behavior. The majority of children who are exposed to traumatic events show remarkable resilience and do not develop psychopathology. That does not mean, however, that the majority is free of distress or emotional pain.
Interventions for children, who live in families which are part of a community that is rooted in a specific culture, need to be comprehensive, systemic and ecological. The expression "it takes a village to raise a child" reflects the need to coordinate the various ecological circles in order to create a continuum of services and synergy between service providers.
Based on the above ideas and principles we suggest the following:
(a). Early detection and triage. There is a need and supporting evidence for the feasibility and effectiveness of early detection of post-traumatic distress from early childhood through adolescence. In line with the recommendation of the World Health Organization who advocate for "Victim identification, care and support programs", it is imperative to start screening and intervention for exposed children as early as possible. The triage for differential interventions should include young children and parents.
(b). Competent parenting for young children is a crucial element of community resilience. Prevention and intervention efforts should focus on enhancing parental capacities to mitigate distress in children and to strengthen their abilities despite the adverse circumstances to provide a secure base for their children. The World Health Organization recommended focusing on "Developing safe, stable and nurturing relationships between children and their parents and caregivers". This recommendation seems crucial and there is a need to develop and test the effectiveness of programs for parenting in war zones. Recent research has shown the centrality of emotion regulation of both parents and children as a protective factor for coping with stress and trauma. This ability for emotion regulation as well as other coping skills should be taught and practiced in schools and communities.
c) Community efforts for enhancing resilience require the creation of a community language of resilience. Such community resilience is based on:
1. Improved communication and collaboration: Effective post-disaster intervention is based on communication between diverse service providers who are responsible for post-disaster interventions, including leadership, medical services, first responders, the educational system, the welfare system and the media.
2. Temporal planning: continuum of services means also an integrated approach to preparedness, prevention, immediate intervention, detection of needs and vulnerable population and long-term planning of needs assessment and interventions.
3. Integrated services: Interventions should meet diverse needs in affected populations. From low-level interventions for children who are non-symptomatic, through community programs for children with moderate symptomatology to full fledged treatment programs for those who have difficulties coping with what they have experienced and may develop PTSD, depression or other forms of psychopathology.

This short review demonstrates that the long-standing Israeli-Palestinian conflict is responsible for the psychological (and physical) wounds of today and the scars of tomorrow. No person, young or old, is left unscathed. Mental health professionals and members of relevant social sectors are needed to mitigate the damage inflicted by violence. The more we are able to understand about trauma and coping in children, the better we will be able to serve a generation of children who will be at the helm of the future of this historic conflict.



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