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Since 1948, the Palestinian people have been subjected to displacement and military occupation, causing significant violent social and psychological pressures (1). To give a relatively recent example, during the violent period known as the Intifada (from 1987 to 1990), children suffered an extremely high incidence of physical trauma both in Gaza and in the West Bank (2,3). Studies using distinct measurement tools have examined the psychological status of Palestinian children. Using several psychometric tools, Miller and others reported a high prevalence of posttraumatic stress disorder (PTSD), conduct disorder, and attention-deficit hyperactivity disorder in children in Gaza, relative to children in a region without conflict (specifically, Ontario) (4). These researchers observed a high prevalence of emotional (36.3%) and behavioural (34.9%) problems, while the prevalence of moderate-to-severe PTSD was 39.5%. A longitudinal study of children in Gaza supported their results (5,6). Notably, when violence in this area lessened, the rates of emotional and behavioural problems in these children decreased significantly (from 27% to 21%, according to the Rutter A2 Scale). Similarly, a study of Gazan children during and after the Intifada observed analogous changes, as indicated by the Traumatic Events Checklist (7,8). Importantly, comparisons of psychological outcomes from Gaza and the West Bank indicate that these children have heterogeneous experiences and responses (1). This heterogeneity must be considered if mental health interventions in both regions are to be effective. Given the lack of studies in the West Bank, we undertook to determine the prevalence of psychological morbidity in children aged 6 to 13 years living in villages in this region. These children have lived their entire lives under military occupation and with increasing demographic pressure from Israeli settlement expansion (9). The principal tool we employed to assess psychological health was the Rutter A2 (parent-answered) Scale (10,11), which measures general psychopathology manifested as emotional and behavioural problems in a population. We report here an alarming rate of psychological morbidity among West Bank children in the summer of 2000, a period of relatively low levels of violence. MethodsTo later compare children living in distinct conditions in the West Bank (for example, in villages vs refugee camps), we initially chose rural villages that were not administered by United Nations refugee and work agencies and had fewer than 20 000 inhabitants. The multistage, random sample design comprised the following: 1) random selection of a single district of the West Bank, 2) random selection of 8 Palestinian rural villages in that district, and 3) random selection of households. We obtained permission from each village council to collect data from households. We obtained consent in all cases by first reading a consent form outlining the nature of the study to each household. A parent (the mother in all but 1 case) then signed the consent form. Questionnaires for approximately 25 children per village, aged 6 to 13 years, were completed. We excluded children in 1 family owing to the recent natural death of the head of the household. Our team of researchers collected data over the course of 2 weeks in July 2002. We measured psychological status using the standardized Arabic version of the Rutter A2 Scale (12). This standardized interview format has been successfully used to measure psychological status in the Gaza. The Rutter A2 scale comprises 31 items rating behavioural and emotional problems (11,12). Potential total scores range from 0 to 62. Children with a total score of 13 or more correlate well as presenting with possible psychological morbidity and requiring detailed psychiatric evaluation. To determine in future studies whether differences in socioeconomic situation (for example, village vs refugee camp) influence psychological morbidity, we assessed socio- economic status according to the Gaza Socioeconomic Adversities Questionnaire (14). ResultsAnalysis of the Rutter A2 Scales (Table 1) revealed that a total of 87 children exceeded the cut-off score of 13. Thus, 42.3% of the children in this West Bank district were flagged for psychological morbidity. Total scores ranged from 0 to 32, with a mean total score of 11.5. Girls had an average score of 10.72, with a prevalence of caseness of 37.8%, while boys had an average score of 12.44, with a prevalence of caseness of 46.3%. Six children from 4 villages had Rutter scores of 30 or greater.
Socioeconomic status results for households revealed that all but 1 family owned their house, 81.5% had an average monthly income of more than 901 NIS (more than US$214), and none were receiving financial assistance (Table 2). For all families, the husband was the sole income earner. With general homogeneity in employment, income, and home ownership, we did not think that socioeconomic adversity significantly affected the rates of caseness.
Discussion and ConclusionsWe demonstrated a high prevalence (42.3%) of psychological morbidity among children in the southern Bethlehem district of West Bank during the summer of 2000. The overall prevalence of psychological morbidity in this region, determined using the Rutter A2 scale, is more than 2 times higher than the reported rate of caseness in Gaza in 2000 (5) ( c2 = 23.26, df 1, P < 0.001). Attention must be paid to the differences in psychological profiles of Palestinian child populations of the West Bank, compared with Gaza. Considering the high prevalence of emotional and behavioural problems during a period of relative calm, we hypo- thesize that the Israeli settlement encroachment may significantly stress Palestinian children and families living in the adjacent isolated West Bank villages. Indeed, recent evidence suggests that, in the absence of direct traumatic events, poor psychological status may arise from anticipating such events (13). Villages in this survey were either within several hundred metres of Israeli settlements and (or) those travelling outside the village had to pass directly adjacent to the settlements (personal observation). Anecdotal evidence revealed that some children refused to attend school if they had to travel near a settlement, because they feared violence. Apart from the presence of the settlements themselves, significant military presence supports this expansion to protect infrastructure connecting the settlements to each other and to Israel (9, personal observation). Our study also supports the suggestion that settlement encroachment has a negative impact: village 4, the only village completely administered by the Palestinian Authority and having the largest self-contained population, had the lowest rate of psychological morbidity among its children. We hypothesize further that Israeli children living in the settlements of the West Bank are not insulated from the psychological effects of living close to a perceived hostile adversary (that is, existing Palestinian villages). It will be important, therefore, to determine the mental health status of Israeli children in settlements in this same West Bank region. The data for our study were collected during July 2000, less than 2 months before significantly escalated violence between Palestinians and the occupying Israeli military (that is, the September 2000 “Al Aqsa Intifada”). We predict further deterioration in the mental health status of Palestinian children in the West Bank. Given that psychological morbidity was above 42% prior to this escalation, the current rate is potentially greater than one-half the population. Funding and SupportTanya Zakrison was funded by a University of Toronto International Health Program Summer Research Scholarship from the Medical Alumni Association of the Faculty of Medicine, University of Toronto. Amira Shahen and Shaban Mortaja were funded by the Al-Quds School of Public Health. AcknowledgementsWe acknowledge the excellent help, advice and encouragement of the members of the Department of Public Health at Al Quds University, specifically Dr Yehia Abed, Dr Abdel Azziz Mousa Thabet, and Dr Ziad Abdeen, Dean of Research. We also acknowledge the assistance of Jad Isaac and Nizar Farqhan at the Applied Research Institute of Jerusalem. Kind appreciation is given to the 8 village councils and participants for their assistance in completing this project. References1. Baker AM. The psychological impact of the Intifada on Palestinian children in the Occupied West Bank and Gaza: an exploratory study, Am J Orthopsychiatry 1990;60:496–505. 2. B’tselem. Annual Report 1989: Violations of human rights in the occupied territories. Jerusalem (IS): B’tselem; 1989. 3. Graff A, Abdolell M. Palestinian children and Israeli state violence. Toronto: Near East Cultural and Education Foundation of Canada; 1991. 4. Miller T, El-Masri M, Allodi F, Quota S. Emotional and behavioural problems and trauma exposure of school-aged Palestinian children in Gaza: some preliminary findings, Medicine. Conflict and Survival 1999;15:368–78. 5. Thabet AA, Vostanis P. Post-traumatic stress disorder reactions in children of war: a longitudinal study. Child Abuse Negl 2000;24:291–8. 6. Thabet AA, Stretch D, Vostanis P. Child mental health problems in Arab children: application of the strengths and difficulties questionnaire. Int J Soc Psychiatry 2000;46:266–80 7. Qouta S, Punamaki RL, El Sarraj E. The impact of the peace treaty on psychological well-being: a follow-up study of Palestinian children. Child Abuse Negl 1995;19:1197–208. 8. Qouta S, El-Sarraj E, Punamaki RL. Mental flexibility as resiliency factor among children exposed to political violence. International Journal of Psychology 2001;36:1–7. 9. Chomsky N. Fateful triangle—the United States, Israel and the Palestinians. Montreal: Black Rose Books; 1999. p 89–180. 10. Rutter M. A children’s behaviour questionnaire for completion by teachers: preliminary findings. J Child Psychol Psychiatry 1967;8(1):1–11. 11. Rutter M, Tizard J, Whitmore K. Education, health and behaviour. London: Longman; 1970. 12. Thabet AA, Vostanis P. Social adversities and anxiety disorders in the Gaza Strip. Arch Dis Childhood 1998;78:439–42. 13. Thabet AA, Abed Y,Vostanis P. Emotional problems in Palestinian children living in a war zone: a cross-sectional study. Lancet 2002;359:1801–4. 14. Abu Hein F, Qouta S, Thabet AA, El Sarraj E. Trauma and mental health of children in Gaza.BMJ 1993;306:1130–1. Author(s)Manuscript received July 2002, revised, and accepted March 2003. 1. Resident, General Surgery Faculty of Medicine, University of Toronto, Toronto, Ontario. 2. Research Associate, School of Public Health, Al-Quds University, West Bank, Palestine. 3. Associate Professor Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario Address for correspondence: Dr P Hamel, 6318 Medical Sciences Building, 1 King’s College Circle, Toronto, ON M5S 1A8 email: paul.hamel@utoronto.ca
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