Rebecca Clark

INTA 489

April 21, 2017

The Affect of War-Related Trauma on the Mental, Emotional, and Behavioral Health

of Children

I. Introduction:

The researcher for this paper seeks to understand the affects of war-related

trauma on the mental and emotional health of children. For the purpose of this

paper, war-related trauma can be defined as any traumatic event experienced by a

child due to armed conflict in the area in which they live. War-related traumatic

events include but are not limited to witnessing acts of violence (such as seeing a

relative killed), hearing experiences (such as hearing of someone’s death or injury),

and personal traumatic events (such as being personally shot, beaten, or injured in

some way)i. The main mental and emotional health issues that are focused on in this

paper are anxiety, depression, and post-traumatic stress disorder. The Middle East,

mostly Israel, Palestine and Lebanon, are the focus of this paper. The researcher is

studying this topic to better understand the affect of war-related trauma on children

in war-torn areas. The purpose is to consider the factors involved in a child’s

resiliency or susceptibility to developing emotional problems after repeated

exposures to war-related trauma.

II. Literature Review:

In a study titled “The Relationship between War Trauma, PTSD, Depression

and Anxiety among Palestinian Children in the Gaza Strip” by Abdelaziz M. Thabet,

the researcher studied a sample of 251 children from 3 summer camps located in

the Gaza Stripii. This article studied the affect of war on the mental health of

Palestinian children in the Gaza Stripiii. They specifically discussed relationship

between war trauma and depression, anxiety, and post-traumatic stress disorderiv.

The children ranged in age from 6-16v. The study used five scales:

sociodemographic scale, Impact of Events Scale, Gaza Traumatic Events Checklist,

Children Revised Manifest Anxiety Scale, and Child Depression Inventoryvi. 59% of

children displayed clinical-range post-traumatic stress disorder symptomsvii. 21.9%

of children had anxietyviii.

“A Systematic Review on the Mental Health of Children and Adolescents in

Areas of Armed Conflict in the Middle East”, a study by Lydia Dimitry, focuses on

several nations in the Middle Eastix. It seeks to understand the affect war has on the

mental, emotional, and cognitive health of children in the Middle Eastx. The word

used to describe war is “armed conflict”xi. The study sought to see how exposure to

armed conflict affected the mental health of childrenxii. Specific conflict-related

experiences include but are not limited to personal exposure, near-miss exposure,

knowing someone injured/killed, family member injured/killed, witnessing people

get injured/killed, hearing bomb explosions, hearing terrorist shooting, exposure to

terror-related media, experiencing home being shelled or demolished, being tear

gassed, seeing wounded people and mutilated bodies on TV, bereavement, being a
witness to violent acts, emigration, separation from parents/family members,

physical injuries, lack of basic needs, water shortage, electricity cuts, changed

economic status, and displacementxiii. The study researched Israel, Palestine,

Lebanon, and Iraq to gather data on war-related affects on childrenxiv. It used 71

scholarly papers to create the review. There were 52, 977 participants total in the

full review (including all papers used)xv.

There are many factors that contribute to the mental, behavioral, and

emotional problems children face after traumatic experiencesxvi. For this reason, the

researcher of this article split these factors into two groups: risk factors and

protective factorsxvii. Risk factors showed many positive correlations between

traumatic experiences/exposures and mental, behavioral, and emotional

problemsxviii. Protective factors showed that certain factors involving a child’s safety

and wellbeing were associated with either resiliency or susceptibility to developing

mental, behavioral, and emotional problemsxix. For example, a supportive family

increased resiliency, while maternal anxiety increased susceptibilityxx.

In another study by Abdelazis M. Thabet (along with a few colleagues), the

impact of war on the comorbidity of PTSD, ADHD, and oppositional defiant disorder

was researchedxxi. The study was called “Comorbidity of Post Traumatic Stress

Disorder, Attention Deficit with Hyperactivity, Conduct, and Oppositional Defiant

Disorder in Palestinian Children Affected by War on Gaza”xxii. They studied children

in Palestine 6 months after the war on Gaza, which lasted for 23 daysxxiii. They

surveyed the entire Gaza stripxxiv. 410 Palestinian children between the ages of 8

and 18 were surveyed in this studyxxv. 224 were boys and 186 were girlsxxvi. The
Gaza Strip has experienced war and conflict for the past 4 decadesxxvii. Because of

this, Palestinian children are often exposed to traumatic experiences due to the

conflictxxviii. Many have lost family members and friends and have experienced the

affects of war-related incursions directlyxxix. This study used the “Gaza Traumatic

Checklist—War on Gaza” to measure children’s experience of traumatic eventsxxx.

They also used a PTSD index to measure levels of PTSDxxxi. To measure ADHD

prevalence, they used the “ADHD scale for parents and self”xxxii. Additionally, they

used scale for conduct disorder and oppositional disorderxxxiii. It is important to note

that they took into consideration all the various types of trauma that children might

experiencexxxiv. For instance, they noted traumatic experiences such as loss of

electricity or water, hearing shelling of artillery, seeing mutilated bodies on TV,

leaving home for better safety, and hearing loud jet fighter planesxxxv. They also

noted the psychological, mental, emotional, and behavioral reactions and

experiences of children such as PTSD, inattentiveness, impulsiveness, oppositional

defiant disorder, attention deficit, and hyperactivityxxxvi. They collected

sociodemographic information along with other information using the War on Gaza

Traumatic Events Checklist, the PTSD Index for DSM-IV Diagnosis: Adolescent Version,

the ADHD Structured Clinical Interview of Mothers and Fathers for DSM-IV Diagnosis,

the Conduct Disorder Questionnaire DSM-IV Diagnosis, and the Oppositional Defiant

Disorder Questionnaire DSM-IV Diagnosisxxxvii.

In a study titled “Risk and Resilience Trajectories in War-Exposed Children

across the First Decade of Life”, the researchers sought to assess the affects of war-

related traumatic experiences on childhood psychopathologyxxxviii. They sought to

determine what caused a higher susceptibility (or higher resiliency) in childrenxxxix.

The article looked at factors such as maternal uncontained style and maternal

emotional distress as possible predictors of a child’s psychological trajectoryxl. The

study screened children for post-traumatic stress disorder, anxiety, depression,

ODD or conduct disorder, and Attention Deficit Hyperactivity Disorderxli. The study

was conducted with a unique cohort over the course of 10 yearsxlii. They did three

tests of each child, one during early childhood (1.5-5 years of age), one during

middle childhood (5-8 years of age), and one during late childhood (9-11 years of

age)xliii. They surveyed children Sderot, Israel, a town very near the border with

Gaza. The article explained that there have been “repeated, unpredictable missile

attacks for over 15 years” in Sderotxliv. This means that children are consistently

experiencing traumatic events. Children in this study came from the same

“frontline” neighborhoods and therefore had fairly uniform experiences of traumaxlv.

Resilience can be defined as “an outcome, a strategy, a set of capacities or a

quality”xlvi. Resilience is considered “a good adaptation under extenuating

circumstances; a recovery trajectory that returns to baseline function following a

challenge”xlvii. There are four categories that predict an increased resilience in

children in a community that has experienced war-traumaxlviii. These four capacities

are information & communication, economic development, social capital, and

community competencexlix.

The various studies discuss many factors that may influence a child’s

likelihood of developing mental, emotional, or behavioral issues after repeated

exposure to war-related trauma. These factors predict a child’s risk or resilience

trajectoryl. Predicting factors include but are not limited to risk factors, protective

factors, temperamental factors, number of exposures to war-related trauma, age,

gender, and level of religious involvementli.

Risk factors showed many positive correlations between traumatic

experiences/exposures and mental, behavioral, and emotional problemslii. The

number of exposures a child had to armed conflict was positively correlated with

PTSD, depression, and anxietyliii. It was also positively correlated to functional

impairment, risk-taking behavior, and emotional disorders, and behavioral

problemsliv. Examples of exposure that increased a child’s likelihood of getting PTSD

were losing one’s home, witnessing a friend being beat, day raids, being tear-gassed,

and suffering violent acts, among several otherslv. These are examples referred to as

“objective exposure”lvi. Objective exposure is defined as “direct physical exposure or

exposure through a relationship with a victim of a terror attack”lvii. Another type of

exposure is “subjective exposure”lviii. Subjective exposure is “the cognitive and

emotional experiences following a traumatic event”lix. Subjective exposure “is the

strongest predictor of mental health outcomes”lx. Subjective exposure is positively

correlated with PTSDlxi.

Older children tend to have higher levels of objective exposurelxii.

Contradicting research makes in unclear as to whether gender has to do with levels

of objective exposurelxiii. Some studies show that boys have higher levels of objective

exposure and researchers suggest that this is likely due to cultural gender roles in

the Middle Eastlxiv.

 It is important to understand what makes children and communities more

resilient after experiences of war-related traumalxv. There are many specific

strategies that might be used to help decrease the likelihood of children developing

mental and emotional problems after experiences of war-related traumalxvi. This

article suggests that both preventive and post-disaster interventions are key in

producing the highest rates of resiliency and recoverylxvii. They suggest that five

sectors of the community should be involved in this process (local schools, social

institutions, medical centers, community leadership, and welfare units)lxviii. The use

of “community capital” plays a significant role in the resilience of children in the

communitylxix. The integration of organizations, families, and communities in

interventions prove to have the most positive effect on increasing a child’s resiliency

to developing mental and emotional health problemslxx.

In Israel, the population has undergone repeated exposures to war-related

trauma in the form of missile attacks and other conflict-related security offenseslxxi.

The Gulf War, Second Lebanon War, and the War in Gaza have all created a sense of

instability and lack of safetylxxii. Many children have found themselves displaced to

the conflictslxxiii.

The Urban Resilience Model is a program that has been implemented in 18

cities in Israellxxiv. Through this program, researchers have found that by creating

networks and layers of support in at-risk communities, children experience higher

levels of resilience following exposures to war-related traumalxxv. This program is

run by the Home Front Defense Ministry in Israel, and is based off of the Cohen-

Harris Center’s model for civilian resiliencelxxvi.

 Health and mental resilience is higher in children when they receive proper

care surrounding a war-related traumatic experiencelxxvii. It is key for medical

personnel and school staff to be trained as mental health mediatorslxxviii. When these

people, who are already established in leadership roles in children’s lives, are

trained to intervene by providing mental health support within their given context,

children have increased resiliencylxxix. These mediators work under the supervision

and guidance of hospital social workers and school counselors/psychologists,

respectivelylxxx. Another factor that has shown positive association with increased

mental health in children after a war-related traumatic event are well-baby

clinicslxxxi. The government, in collaboration with local agencies and aid

organizations, run these well-baby clinicslxxxii. Pediatric health clinics, such as these,

are an example of the use of social capital to enhance the resilience of children after

war-related traumatic experienceslxxxiii.

School resilience is another important factor in predicting the risk or

resilience a child has in developing mental or emotional health problems following

war-related traumatic experienceslxxxiv. Schools provide an optimal mode of

intervention because they are an active part of large populations of children in the

country since school attendance is compulsorylxxxv. School settings provide an

already established structure and safety that was present before the traumatic

experience, so children are more likely to seek and be willing to receive helplxxxvi.

Some children experience concentration difficulties or behavioral issues, which

teachers are able to notice and intervene appropriatelylxxxvii. A school setting

normalizes the process of post-trauma intervention, increasing the rates of

resiliencylxxxviii.

III. Theory & Hypothesis:

H1: Experiences of war-related trauma negatively affect the mental and

emotional health of children.

IV. Research Design:

The researcher analyzed scholarly articles and peer-reviewed research

papers related to the topic of war-related trauma and it’s relation to mental and

emotional health in children. The researcher organized the findings in order to

discuss and address the hypothesis: Experiences of war-related trauma negatively

affect the mental and emotional health of children.

V. Data Analysis & Discussion:

In December 2008, Israeli forces attacked the Gaza Strip for 23 dayslxxxix. This

long strike resulted in the death of 1420 Palestinians (including 446 children)xc.

Additionally, 5320 others were injured (including 1855 children)xci. It is important

to note the large number of children directly affected by this violent conflict. The

conflict also affected homes—4,000 homes were completely destroyed and 16,000

were partly destroyedxcii.

Gaza is a place where nearly half of the population is children (under age

15)xciii. The annual rate of population growth indicates that this percentage may
increase in the near futurexciv. Children in the Gaza Strip are at high risk for

developing mental health problems because many of them have experienced war-

related traumaxcv.

PTSD, depression, and anxiety rates in children were high in Palestine after

the conflictxcvi. PTSD alone had rates ranging from 40% to 71% according to their

researchxcvii. Their study noted that there was significant comorbidity between

ADHD and PTSD, anxiety, and oppositional defiant disorderxcviii. There was also

comorbidity of PTSD and depression in the children they studiedxcix.

Palestinian children who had experienced traumatic events in the War on

Gaza were likely to show symptoms related to Post Traumatic Stress Disorder as

well as Attention Deficit Disorder (with or without hyperactivity)c. It also explained

that many children display symptoms of both of these disorders, showing that war

puts children at higher risk for developing one or both of these disordersci.

Comorbidity of these two disorders was discovered to be a high possibilitycii.

Among children in the Gaza Strip, 50.6% of children had depressionciii. The

amount of traumatic experiences was positively correlated with post-traumatic

stress disorder, anxiety, and depressionciv. Political violence and war trauma is

related to PTSD depression in children in Palestinecv. Interventions must be done

through already present means—existing emergency aid agenciescvi. These agencies

have already provided support and aid in ways that are culturally appropriate, and

therefore have legitimacy and can provide additional support and services

regarding mental health issuescvii.

 Through the use of the Gaza traumatic events checklist, traumatic

experiences were divided into three domains of trauma: witnessing acts of violence,

hearing experiences, and personal traumatic eventscviii. Witnessing acts of violence

includes seeing a relative killed, seeing people injured, watching one’s home be

destroyed, and experiencing bombardmentcix. Hearing experiences include hearing

of someone’s death or injurycx. Personal traumatic events include personally being

injured (i.e. shot, beaten, etc.)cxi.

There were four most common traumatic events experienced by children in

the Gaza Stripcxii. 85.4% of children had heard shelling of the area by artillery, 81.5%

had heard the sonic sounds of jetfighters, 78.2% had seen mutilated bodies on TV,

and 76.7% had heard bombardment and shootingscxiii. 148 out of the 251 children

were above the cut-off range indicating that they may be diagnosed with post-

traumatic stress disordercxiv. There were no statistically significant differences

between sexes or between agescxv. 55 children out of the 251 were above the cut-off

range for anxiety, indicating that they had anxietycxvi. There were no statistically

significant differences between sexes or between ages here eithercxvii. 127 out of the

251 children in the study were above the cut-off for depression, indicating that they

had depressioncxviii. Again, there were no statistically significant differences between

sexes or between agescxix.

In the Gaza Strip, post-traumatic stress disorder seemed to be associated

with particular types of traumatic eventscxx. Children who witnessed a close relative

being killed or who witnessed a friend’s home destroyed were more likely to

develop post-traumatic stress disordercxxi. Anxiety was predicted by particular

traumatic experiences as wellcxxii. Children who were threatened via telephone to

evacuate their home before a bombardment occurred or who heard bombardment

and shootings were more likely to develop anxietycxxiii. Two traumatic events also

predicted depressioncxxiv. Children who witnessed their own home being destroyed

or who were threatened by shooting were more likely to develop depressioncxxv.

In Israel, Lebanon, and Iraq, protective factors showed that a supportive

family decreased the likelihood of PTSD and the intensity of behavioral

problemscxxvi. Additionally, stress was negatively correlated with having a

supportive familycxxvii. Stress was also positively correlated to how much stress

one’s parents/friends/etc. hadcxxviii. For instance, the more stressed the parents

were, the more stressed the child wascxxix. Maternal anxiety correlated with the

child’s anxietycxxx. The article explains that behavioral problems seemed to be

associated with things like living with a single parent, having less than 2 siblings, or

experiencing punitive parentingcxxxi. Children were more resilient when they had

supportive families, experience more outdoor recreation, and maintained routine

activitiescxxxii. Boys were more likely to have outdoor relaxation activities and seek

friend support, while girls were more likely to be studious and seek self-

reliancecxxxiii. Religious adolescents tended to have less PTSS than those who were

notcxxxiv.

The studies in Israel, Lebanon, and Iraq conclude that “conflict-related

traumatic experiences correlates positively with prevalence of mental, behavioral

and emotional problems”cxxxv. The results must be viewed within the context of

culture and “specific aspects of the conflicts”cxxxvi. Israel, for instance, is relatively
stable as a country and has preserved its infrastructure pretty well, while Palestine

is not stable and has poor infrastructurecxxxvii. These things are important to take

into account when discussing the results of the studycxxxviii. In Lebanon, the civil war

is mostly due to religious sectarianism and the conflict happens sporadicallycxxxix.

This affects how much conflict-related exposure children experiencecxl. Iraq has

experienced sudden conflict that damaged many community and government

buildings (schools, hospitals, etc.)cxli. This limited important resources very

suddenlycxlii.

Older children tend to have more PTSScxliii. They also have higher exposure

levels than do the younger onescxliv. Boys tend to have higher or equal levels

objective exposure, perhaps due to the fact that boys tend to have more exposure to

the outdoors in Middle Eastern culturecxlv. Additionally, girls tend to have more

PTSS, separation anxiety, depression, and other psychological symptoms than

boyscxlvi. Boys tend to have more behavior issues, hyperactivity, and aggressioncxlvii.

This may be because girls are considered/expected to be more caring in the culture,

while boys are expected to be more protective and providing for the familycxlviii.

These differing gender responses would be consistent with the cultural gender

rolescxlix.

When mothers are anxious, children tended to be more anxious. A mothers

anxiety levels were positively correlated to the anxiety levels of the childcl. This may

be because of an impaired parent capacity or a mother’s maladaptive copingcli.

Children’s “mental, behavioral and emotional problems are often minimally

addressed or unnoticed” during times of warclii.

 Social support was negatively correlated to stresscliii. This may be because

family and community are very important aspects of the culture in the Middle

Eastcliv. Additionally, when there is social support, people can relate to each other’s

experiences and bring comfort through understandingclv. Religion seemed to help

resiliency and lower levels of PTSSclvi.

This study found that psychopathology does not heal itself over time. It

states, “chronic stress does not heal naturally, and its effects appear to exacerbate

over time”clvii. Children exposed to trauma seem to be more susceptible to comorbid

and chronic mental health diagnosesclviii. When children experience chronic stress

early in life, it often has lasting effects on both physical and mental healthclix.

Therefore, it is important to study various factors that may predict individual risk

and resilience trajectories. In this study, the researchers studied specific maternal

and child factors to help shed light on this issue. The article states, the effect of

chronic trauma in early childhood appears to intensify over time as it depletes the

child’s resources from investing in age-appropriate tasks”clx.

The children in this study, from Sderot, Israel, have experienced repeated

and unpredictable traumatic eventsclxi. The children were exposed to the same

wartime stressors, as they were all from the same area neighborhoodsclxii. Risk and

resilience are reflections of a child’s developmental processesclxiii. The child’s

developmental processes depend on both the individual child and on the child’s

contextclxiv. This study followed four trajectories that a child might experienceclxv.

The first was that the child never developed symptoms of any disorderclxvi. The

second trajectory was that the child developed symptoms early on, but then
recovered laterclxvii. The third trajectory was that a child had symptoms early on and

continued to have symptoms at later testsclxviii. The fourth trajectory was that a child

had no symptoms early on but then developed symptoms when they were olderclxix.

This study found that maternal behavior affected a child’s risk/resilience in regards

to mental health issues after experiencing traumaclxx. A mother’s emotional distress

can affect the quality of parenting she is able to give a childclxxi. It is important to

note that many mothers experience depression, anxiety, and post-traumatic stress

after experiencing traumatic eventsclxxii. Symptoms of these disorders can hinder a

mother from providing the best quality of parenting to her childclxxiii. She may be

fearful herself, and unable to contain her child’s fearsclxxiv. When a child’s fears are

uncontained, they are more likely to experience more fear and uncertainty, causing

their symptoms to worsen and raising the likelihood of developing mental health

problemsclxxv. When a mother’s caregiving is compromised by her own distress, it

can exacerbate the child’s psychopathologyclxxvi.

Another indicator of a child’s risk or resilience in developing mental health

issues after being exposed to trauma is the child’s temperamental factorsclxxvii. The

temperamental factor that is of particular importance in this study is a child’s social

engagementclxxviii. The study sought to identify whether a child was active in social

interactions or notclxxix.

It is difficult to cope with mass emergencies in community settingsclxxx. War-

related trauma is associated with “extensive physical and psychological illness”clxxxi.

This article uses the word “disaster” to refer to what I am calling “war-related

trauma”clxxxii. A disaster is a “relatively sudden, more or less time-limited and public

event that causes extensive damage to property and life and has a continuous,

systemic and disruptive impact on the social network and basic daily routines of

children and families”clxxxiii.

Disasters are made up of four stagesclxxxiv. The first stage is the pre-disaster

stage, where “an imminent threat is identified and the population alerted”clxxxv. The

second stage is the event itself, where there are “efforts to minimize damage by

protecting human life and meeting the population’s basic needs”clxxxvi. The third

stage is the “resultant massive structural and functional changes to society”clxxxvii.

These lead to “regression and lost norms”clxxxviii. The fourth stage is the collective

ideology and identityclxxxix.

After experiencing war-related trauma, children are susceptible to

experience mental and emotional health problems such as posttraumatic stresscxc.

They may also experience grief and dissociationcxci. Children are more vulnerable

than adults because they are undergoing natural developmental changes at this

stage of life, and these may be disrupted significantly through an experience of

disastercxcii. For instance, especially in early childhood, children are developing a

sense of self and identitycxciii. They are also learning to regulate impulses and

developing both a sense of attachment to people and a sense of securitycxciv. All of

these important development changes may be disrupted by the experience of war-

traumacxcv. When these changes are not allowed to grow and develop as they should,

it can increase a child’s likelihood of developing psychological pathologycxcvi.

To increase the resilience of children in a community, it is important to equip

various groups of people to help intervene in situations of war-traumacxcvii.

Resiliency is increase the sooner a child has the opportunity to re-establish positive

attachments to people and a feeling of safety and securitycxcviii. Social support has

been found to decrease a child’s susceptibility to developing mental and emotional

health issuescxcix.

Social capital increases the likelihood of resilience in children following war-

related traumacc. Social capital is defined as “mutual trust and social networking

among individuals and groups as they willingly partake in mutually beneficial

collective actioncci. Children tend to have better mental health outcomes when there

are higher levels of social capital in their community following a disasterccii. Social

capital allows for communities to establish a sense of safety and security at

individual, familial, communal, and institutional levelscciii. This allows for a child’s

protective matrix to be addressed, and thus increasing the likelihood of resilience

after war-related traumatic experiencescciv.

VI. Conclusion:

Based on widespread research of many different groups of children who

have had repeated experiences of war-related trauma, war-related trauma

significantly increases a child’s susceptibility to developing mental and/or

emotional health issues. The researcher concludes that experiences of war-related

trauma negatively affects the mental and emotional health of children.

Children tend to develop mental health problems due to war-related

traumaccv. It is important to focus on children in war zones in order to provide

support and interventions in order to ensure the well-being and resiliency of the
childrenccvi. They are the next generation. Children who experience war-related

trauma, whether subjective experiences or objective experiences, may not receive

the emotional, mental, behavioral, and psychological support they need to overcome

the difficulties associated with the traumatic experiencesccvii. It is important that

these be addressed during times of war to ensure that the next generation is able to

grow and develop healthily so they can have the most positive futureccviii. It should

be a goal to help children thrive despite the hard circumstances they and their

families and communities have experiencedccix.

It is important for already-existing emergency agencies to take on the work

of providing these additional services for childrenccx. These agencies have already

been working in a culturally appropriate capacity in local communities and

therefore can better provide the care and support needed by the children in their

areasccxi. It is important to help work towards providing a sense of stability and help

children develop positive coping strategiesccxii. Parents and teachers need to be

given resources to help children who are affected by these disordersccxiii. Medical

personnel and school staff can act as mental health mediators to increase child

resiliencyccxiv. These disorders can affect how students perform in school and at

home, and it is important to help them develop positive coping strategies and help

them to work through the difficult events they have experienced from conflict in

their countryccxv. Local communities, governments, and organizations should

collaborate in the use of social capital to aid children who have developed mental

and emotional health problems and to decrease the susceptibility in those who have

not developed these disordersccxvi. International organizations like the UN and

UNICEF need to play an important role and may be a helpful resource in providing

the necessary care for children through the already-existing local agenciesccxvii

i Thabet, Abdelaziz M. . "The Relationship between War Trauma, PTSD, Depression,

and Anxiety among Palestinian Children in the Gaza Strip." Health Science

Journal, 3rd ser., 10, no. 5 (July 22, 2016): 1-8. Accessed March 29, 2017.

doi:10.4172/1791-809X.1000100503.

ii Ibid.

iii Ibid., 1

iv Ibid.

v Ibid., 2

vi Ibid., 3

vii Ibid., 5

viii Ibid.

ix Dimitry, Lydia. "A systematic review on the mental health of children and

adolescents in areas of armed conflict in the Middle East." Child: Care, Health

and Development 38, no. 2 (April 3, 2011): 153. doi:10.1111/j.1365-

2214.2011.01246.x.

x Ibid.

xi Ibid.

xii Ibid.

xiii Ibid., 154

xiv Ibid.

xv Ibid.
xvi Ibid., 156

xvii Ibid.

xviii Ibid.

xix Ibid.

xx Ibid.

xxi Thabet, Abdelaziz M., Ahmad Abu Tawahina, Eyad El Sarraj, David Henely,

Henrick Pelleick, and Panos Vostanis. "Comorbidity of post traumatic stress

disorder, attention deficit with hyperactivity, conduct, and oppositional

defiant disorder in Palestinian children affected by war on Gaza." Health 05,

no. 06 (April 15, 2013): 994. doi:10.4236/health.2013.56132.

xxii Ibid., 994-1002

xxiii Ibid., 994

xxiv Ibid.

xxv Ibid., 996

xxvi Ibid.

xxvii Ibid., 995

xxviii Ibid.

xxix Ibid., 996

xxx Ibid.

xxxi Ibid.

xxxii Ibid.

xxxiii Ibid., 997

xxxiv Ibid.
xxxv Ibid.

xxxvi Ibid., 997-999

xxxvii Ibid., 996-997

xxxviii Halevi, Galit, Amir Djalovski, Adva Vengrober, and Ruth Feldman. "Risk and

resilience trajectories in war-exposed children across the first decade of

life." Journal of Child Psychology and Psychiatry 57, no. 10 (2016): 1183.

doi:10.1111/jcpp.12622.

xxxix Ibid.

xl Ibid., 1187

xli Ibid.

xlii Ibid., 1185

xliii Ibid., 1184

xliv Ibid.

xlv Ibid.

xlvi Hamiel, Daniel, Leo Wolmer, Smadar Spirman, and Nathaniel Laor.

"Comprehensive Child-Oriented Preventive Resilience Program in Israel

Based on Lessons Learned from Communities Exposed to War, Terrorism

and Disaster." Child & Youth Care Forum 42, no. 4 (March 21, 2013): 263.

Accessed April 13, 2017. doi:10.1007/s10566-013-9200-7.

xlvii Ibid.

xlviii Ibid.

xlix Ibid.

l Halevi, 1187
li Dimitry, 153-161

Thabet, Comorbidity of post traumatic stress disorder, attention deficit with

hyperactivity, conduct, and oppositional defiant disorder in Palestinian

children affected by war on Gaza, 994-1002

Halevi, 1183-193

Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 1-8

lii Dimitry, 156

liii Ibid.

liv Ibid.

lv Ibid.

lvi Ibid.

lvii Ibid.

lviii Ibid.

lix Ibid.

lx Ibid.

lxi Ibid.

lxii Ibid.

lxiii Ibid.

lxiv Ibid.

lxv Hamiel, 261

lxvi Ibid.

lxvii Ibid.
lxviii Ibid.

lxix Ibid.

lxx Ibid., 262

lxxi Ibid., 263

lxxii Ibid.

lxxiii Ibid.

lxxiv Ibid., 265

lxxv Ibid.

lxxvi Ibid.

lxxvii Ibid., 264

lxxviii Ibid., 266

lxxix Ibid.

lxxx Ibid.

lxxxi Ibid.

lxxxii Ibid.

lxxxiii Ibid.

lxxxiv Ibid., 268

lxxxv Ibid.

lxxxvi Ibid.

lxxxvii Ibid.

lxxxviii Ibid.
 lxxxix Thabet, Comorbidity of post traumatic stress disorder, attention deficit with

hyperactivity, conduct, and oppositional defiant disorder in Palestinian

children affected by war on Gaza, 995

xc Ibid.

xci Ibid.

xcii Ibid.

xciii Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 1

xciv Ibid.

xcv Ibid.

xcvi Thabet, Comorbidity of post traumatic stress disorder, attention deficit with

hyperactivity, conduct, and oppositional defiant disorder in Palestinian

children affected by war on Gaza, 1001

xcvii Ibid., 995

xcviii Ibid., 999

xcix Ibid.

c Ibid.

ci Ibid.

cii Ibid.

ciii Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 5

civ Ibid., 6

cv Ibid., 6
cvi Ibid., 7

cvii Ibid.

cviii Ibid., 3

cix Ibid.

cx Ibid.

cxi Ibid.

cxii Ibid., 4

cxiii Ibid.

cxiv Ibid., 5

cxv Ibid.

cxvi Ibid.

cxvii Ibid.

cxviii Ibid.

cxix Ibid.

cxx Ibid., 6

cxxi Ibid.

cxxii Ibid.

cxxiii Ibid.

cxxiv Ibid.

cxxv Ibid.

cxxvi Dimitry, 156

cxxvii Ibid.

cxxviii Ibid.
cxxix Ibid.

cxxx Ibid.

cxxxi Ibid.

cxxxii Ibid.

cxxxiii Ibid.

cxxxiv Ibid.

cxxxv Ibid., 157

cxxxvi Ibid.

cxxxvii Ibid.

cxxxviii Ibid.

cxxxix Ibid.

cxl Ibid.

cxli Ibid.

cxlii Ibid.

cxliii Ibid.

cxliv Ibid.

cxlv Ibid.

cxlvi Ibid.

cxlvii Ibid.

cxlviii Ibid.

cxlix Ibid.

cl Ibid., 158

cli Ibid.
clii Ibid.

cliii Ibid., 157

cliv Ibid.

clv Ibid.

clvi Ibid., 158

clvii Halevi, 1183

clviii Ibid., 1183-1193

clix Ibid., 1183

clx Ibid., 1184

clxi Ibid.

clxii Ibid.

clxiii Ibid.

clxiv Ibid.

clxv Ibid.

clxvi Ibid.

clxvii Ibid.

clxviii Ibid.

clxix Ibid.

clxx Ibid.

clxxi Ibid., 1184-1185

clxxii Ibid., 1185

clxxiii Ibid.
clxxiv Ibid.

clxxv Ibid.

clxxvi Ibid.

clxxvii Ibid.

clxxviii Ibid.

clxxix Ibid.

clxxx Hamiel, 262

clxxxi Ibid.

clxxxii Ibid.

clxxxiii Ibid.

clxxxiv Ibid.

clxxxv Ibid.

clxxxvi Ibid.

clxxxvii Ibid.

clxxxviii Ibid.

clxxxix Ibid.

cxc Ibid.

cxci Ibid.

cxcii Ibid.

cxciii Ibid.

cxciv Ibid.

cxcv Ibid.

cxcvi Ibid.
cxcvii Ibid.

cxcviii Ibid.

cxcix Ibid.

cc Ibid., 263

cci Ibid.

ccii Ibid.

cciii Ibid.

cciv Ibid.

ccv Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 1

ccvi Ibid., 7

ccvii Dimitry, 158

ccviii Ibid.

ccix Ibid.

ccx Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 7

ccxi Ibid.

ccxii Ibid.

ccxiii Thabet, Comorbidity of post traumatic stress disorder, attention deficit with

hyperactivity, conduct, and oppositional defiant disorder in Palestinian

children affected by war on Gaza, 1001

ccxiv Hamiel, 268

ccxv Thabet, Comorbidity of post traumatic stress disorder, attention deficit with

hyperactivity, conduct, and oppositional defiant disorder in Palestinian

children affected by war on Gaza, 994-1002

ccxvi Hamiel, 263

ccxvii Thabet, The Relationship between War Trauma, PTSD, Depression, and Anxiety

among Palestinian Children in the Gaza Strip, 7

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