Palestinian Children: Victims of Decades of Violence and Trauma

In the following paper, we will highlight the historical, socio economical, and political context of Palestinians living in the Occupied Territories. During the last two decades many historical and political events had occurred. From the first Intifada to Oslo agreement to Al Aqsa Intifada to factional fighting, and lastly the Gaza siege. Political violence inflicted on Palestinians escalated day after day and oppression methods changed from time to time.


Introduction
In the following paper, we will highlight the historical, socio economical, and political context of Palestinians living in the Occupied Territories. During the last two decades many historical and political events had occurred. From the first Intifada to Oslo agreement to Al Aqsa Intifada to factional fighting, and lastly the Gaza siege. Political violence inflicted on Palestinians escalated day after day and oppression methods changed from time to time.

Demography
The Gaza Strip is an elongated stretch of land on the Mediterranean Sea, located between Israel and Egypt. It measures 50km in length and its width ranges from 5 Kilometers in the north to 12km in the south. When the armistice lines were drawn between Israeli and Arab forces in 1949, only two areas of historic Palestine remained in Arab hands: the West Bank of the river Jordan and a 140km-square area of territory around the port city of Gaza, packed with refugees from the 1948 forced uprooting that became known as the Gaza Strip. Originally administered by neighbouring Egypt, Gaza was seized and occupied by Israeli forces in the June war of 1967.
With a population of 1,416, 546 million people, Palestinian Central Bureau of Statistics estimations indicate that the population density in the Palestinian Territory was 625 persons/ km2 in the end of 2007. In the West Bank, the density was 415 persons/km2 while in Gaza Strip, the density raised to 3,881 persons/km2. In Israel the population density in 2007 was approximately 317 person/km2 of Arabs and Jews.
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, 2006).
Gaza population is considered a young society as almost half the population of the Gaza Strip is under the age of 15 years. This is likely to increase in the near future, because of the annual rate of population growth (6%). Children living in the Gaza Strip have been exposed to and are suffering from a range of trauma and abuse, which out them at high risk factor for the development of mental health problems in young life and their continuation into adulthood and the next generation of parents.
of social and economic control, land seizures and an 'iron fist' response to all forms of dissent)-Intifada. This turned Gaza into a political powder keg that finally exploded in December 1987, when four Gazans were killed in a traffic accident involving an Israeli military vehicle. Initial protests over the deaths rapidly escalated into mass demonstrations and thousands of Gazans took to the streets to erect barricades and began their stonethrowing campaign. Within a week, the protests had spread to the entire areas of the Gaza Strip and the West Bank, and were being referred to as the Intifada-the uprising. The Intifada was to last for seven years, and the tactics of the violent Israeli crackdown during that period resulted in terrible and longlasting consequences for the entire Palestinian population and its purpose to end the military occupation. Over 1,100 Palestinians were killed in the occupied territories during the seven years of the Intifada.

Effect of Political Violence in Palestinian Children Wellbeing
Decades of violence and trauma inflicted on Palestinians living in Gaza Strip had a negative effect on children and family mental health. The mental health problems ranged from simple fears and anxiety to full criteria of PTSD, anxiety, depression and other mental health problems.
Baker [1] studied Palestinian children in the middle period of the Intifada, in the summer of 1989, when confrontation against the occupiers had collectively resulted in feelings of power and pride. We have to keep in mind that the Intifada, in also involved a great suffering for its participants: loss of life and casualties were frequent and collectively punishment such as house demolitions, curfews, and nightly raids were commonly used against the population. This research relates to the last and maybe most tragic months of the community.
Thabet et al. [2], in study of 72 Palestinian children showed that the most common traumatic events for the children attending our clinic were witnessing acts of violence against relatives or non-relatives, beating to themselves, and being injured by shooting. The most common cases were from Gaza, which included the beach camp and other crowded areas of Gaza. In the camps area the bad socioeconomic status of children living at that area is another factor in making our children more vulnerable to trauma. Results showed that post-traumatic stress disorder symptoms could change according to cultural background. This was supported by findings of that 12 cases had developed conversion disorder symptoms in the form of conversion fits it has been observed that persons in Eastern culture people react to stressful conditions by showing somatoform symptoms which include motor, sensory, and dissociative symptoms.
Researchers from the Gaza Community Mental Health Programme, in an epidemiological study of Palestinian children, found that, out of 1,564 children, 96% had experienced night raids, 49.8% had been subjected to physical beatings (which resulted in 8.7% having their bones broken), and 29% had been shot or wounded [3].
Thabet [4] in a clinical study described his impression and descriptive data from the group of traumatized children treated by group therapy here seem to support the notion that group therapy is an effective therapy in traumatized children to some extend and this was apparent in observing the decline in scoring of PTSD, avoidance and intrusion scores after three months of therapy. However, in looking to Rutter scale there was no much difference in period of three months and this support other opinions that Rutter scale in not a good measure in case if traumatic experience. Another reason of no change of Rutter scale is the fact that most of those children were chronically traumatized and some of the neurotic and behavior problems they have are due to the previous traumatic experiences. From our observation during the therapy session some of those children were obsessed with the Special Israeli Forces especially Mohammed. The therapy session was done in a transition period between the end of Isaerli's occupation to Gaza Strip and coming of the Palestinian police and it was apparent in their drawings the change from pictures full of killing, guns, and blood to another shining picture of the Palestinian coloured flags and slogans welcoming the Palestinian police.
Quato et al. [5] studied 436 children from 2-17 years of age were surveyed to examine the effects of deportation on their psychological and emotional life. The results showed that high level of emotional psychological and behavior problems were found among children of the deportees.
Quata et al. [6], in study of Palestinian children lived in the occupied Gaza Strip during the Intifada. The result showed that the sex of the child was the most important determinant of cognitive capacity. Girls were found to be more intelligent and creative than boys are. The result can be interpreted as resulting from the socialization of girls in the contemporary Palestinian society. Girls are educated inside the house and are under stricter surveillance and protection than boys. At the same time, girls "girls are expected both to help in the home as well as to perform well in school. Maybe, due to these double demands for the girls achievement, their intelligence and creative capacity surpass those of boys. Girls also showed a higher self-esteem than the boys in this sample. Our aim was to understand the impact of both exposure to trauma and the child's own participation in Intifada in the affecting cognitive and emotional responses. While trauma and activity did not affect cognitive capacity, the emotional responses were affected. Traumatic experiences predicted high neuroticism and risk-taking and low self-esteem among studied children. We had hypothesized that children's active participation in the Intifada would protect them psychologically from the negative impact the idea that Intifada participation has provided the Palestinian child a mechanism that strengthens his or her self-esteem and saves him or her from psychological suffering. The activity/passivity of participation in the Intifada turned out to be more decisive in affecting the child's self-esteem and risk-taking than exposure to traumatic experiences. Children who were exposed to traumatic experiences in their level of self-esteem and participation were important.
Children with a high level of traumatic experience who activity participated in the Intifada showed more neuroticism than the passive children and those with a low level traumatic experience. Our results differ from earlier studies which show those political hardships and active participation increase self esteem among Palestinian children [1,3]. The high self-esteem may generally be that case among Palestinian children, resulting from their successful fight for freedom and active participation in the Intifada. The present study does not confirm the idea that the Intifada is healing process. The lowest level of self-esteem was found among active children with trauma, while the highest self-esteem was found among both children with no or minor exposure to trauma and those taking a passive stand towards participation in the Intifada. An explanation may involve a time factor.
Thabet et al. [7] investigated the rate and nature of childhood anxiety symptoms and disorders, and their relationship to social adversities in a cultural sample not previously researched. A sample of 237 children of 9-13 years living in the Gaza Strip was randomly selected in a school-based study. Children completed the Revised Manifest Anxiety Scale and teachers completed the Rutter Scale. Children reported high rates of significant anxiety problems (21.5%) and teachers reported even higher rates of mental health problems (43.4%) that would justify a clinical assessment. Anxiety problems, particularly negative cognitions, increased with age and were significantly higher among females. Low socio-economic status was the strongest predictor of general mental health problems. Living in inner-city areas or camps, both common among refugees, was strongly associated with anxiety problems.
Thabet et al. [8] in study of sample consisted of 239 children of 6 to 11 years of age. Measures included the Rutter A2 (parent) and B2 (teacher) scales, the Gaza Traumatic Event Checklist and the Child Post Traumatic Stress Reaction Index. 174 children (72.8%) reported PTSD reactions of at least mild intensity, while 98 (41%) reported moderate/severe PTSD reactions. Caseness on the Rutter A2 scale was detected in 64 children (26.8%), which correlated well with detection of PTSD reactions, but not with teacher-detected caseness. The total number of experienced traumas was the best predictor of presence and severity of PTSD. Intervention programmes for post-war children need to be evaluated, taking into account developmental and cultural aspects, as well as characteristics of the communities involved.
Thabet et al. [9] in a longitudinal study in the Gaza strip with 234 children aged 7 to 12 years, who had experienced war conflict, at one year after the initial assessment, i.e. during the peace process. Children completed the Child Post Traumatic Stress Reaction Index (CPTS-RI), while the Rutter A2 and B2 Scales were completed by parents and teachers. Results showed that the rate of children who reported moderate to severe PTSD reactions at follow-up had decreased from 40.6% (N=102) to 10.0% (N=74). 49 children (20.9%) were rated above the cutoff for mental health problems on the Rutter A2 (parent) Scales, and 74 children (31.8%) were above the cut-off on the Rutter B2 (teacher) Scales. The total scores on all three measures had significantly decreased during the one-year period. The total CPTS-RI score at follow-up was best predicted by the number of traumatic experiences recalled at the first assessment.

Political Violence due to Al Aqsa Intifada
On September 2000, the Al aqsa Itifada erupted. Within seven months, 400 Palestinians had been killed and several thousands were injured, with approximately 40% of them being children under 18 years. Children and families have been exposed to a variety of traumatic events, ranging from hearing of killing, to bombardment by helicopters at the entire Gaza Strip.
The second Intifada (Al Aqsa Intifada) differs from the previous Intifada, in which events such as night and day raids were common occurrence in previous Intifada (1987)(1988)(1989)(1990)(1991)(1992)(1993). Also severity and intensity of traumatic events increased so much and changed types of new traumatic events such bombardment, shelling by tanks, and home demolition, and using people as human shields to arrest people. Thabet et al. [10] in study of 286 Palestinian children aged 9-18 years, and using revised version of Gaza Traumatic Events Checklist, Impact of Events Scale (IES), and General Health Questionnaire (GHQ-28). Children experienced an average number of four traumatic events, both direct experience of violence and through adults or the media. One third of the children (67%) reported significant posttraumatic stress reactions. IES scores were higher among girls, despite boys' higher exposure to conflict. Mothers' GHQ scores significantly predicted children's IES scores.
One of the devastating effect of Israelis measures were home bombardment and demolition which left hundreds of families without home and living in tents exposed to the rainy days of winter and sunny days of summer.
Thabet et al. [11] in study of ninety one children exposed to home bombardment and demolition during Al Aqsa Intifada and a 89 control group, who had been exposed to other types of traumatic events homes were interviewed about post traumatic, anxiety, and fear symptomatology. Children exposed to home demolition reported significantly more PTSD and fear symptoms than the control group. Exposure group reported less anxiety symptoms than the control group.
Thabet et al. [12] in study 403 Palestinian children aged 9-15 years selected from 4 summer camps, showed that Children experienced a wide range of traumatic events, both direct experience of violence and through the media. Both CPTSD-RI and MFQ scores were independently predicted by the number of experienced traumatic events. Exposure to trauma ceased to have significant impact on depressive symptoms, in the presence of PTSD symptoms. The PTSD items whose frequency was significantly associated with total MFQ scores, were: sleep disturbance, somatic complaints, constricted affect, impulse control, and difficulties in concentration.
In order to investigate the Palestinian children ways of dealing with stress and trauma and presence of coping strategies which may mediate the effect of the trauma on children a number of studies were conducted In study of Thabet et al. [13] to establish the nature and extent of maltreatment experiences, coping strategies, and behavioural/emotional problems, and their relationships, in a sample of Palestinian adolescents. A study of 97 male adolescents aged 15-19 years, and attending a vocational training centre based in the Gaza Strip. Adolescents completed the Child Maltreatment Schedule and the Ways of Coping Scale (WAYS). The Strengths and Difficulties Questionnaire (SDQ) was completed by adolescents and by their teachers. Findings revealed high rates of emotional and physical maltreatment. Reliance on emotion-focused or avoidant coping strategies was associated with exposure to maltreatment. Use of maladaptive coping also predicted emotional difficulties in the respondents.
Gillian Lewando Hundt et al. [14] looks at the limitations and strengths of using the A cope questionnaire for measuring strategies for coping with prolonged conflict by Palestinian young people in Gaza. The scale was administered to young people between the ages of 8-17. The results show some gender differences in coping strategies. However, some items on the sub scales are not relevant for Muslim societies or in situations of prolonged conflict. The authors suggest that combining an anthropological contextual perspective and qualitative data with psychological instruments is an effective way of addressing the limitations of using a single quantitative method of assessment in non western complex social and cultural settings.
Studies of effect of trauma in preschool children were rare in the area. This age group is influenced by many environmental and intra familiar factors which may affect their psychosocial development later on.
Thabet et al. [15] in a study investigating the relationship between exposure to war trauma with behavioural and emotional problems among pre-school children. 309 pre-school children aged 3-6 years were selected from kindergartens in the Gaza Strip, and were assessed by parental reports in regard to their exposure to war trauma (Gaza Traumatic Checklist), behavioural and emotional problems (Behaviour Checklist -BCL; Strengths and Difficulties Questionnaire-SDQ). Pre-school children were exposed to a wide range of traumatic events. The total number of traumatic events independently predicted total BCL and SDQ scores. Exposure to day raids and shelling of their houses by tanks were significantly associated with total behavioural and emotional problems scores. We concluded that direct and nondirect exposure to war trauma increases the risk for behavioural and emotional problems among pre-school children, which may present as non-specific psychopathology.
Thabet et al. [16] in study of 349 children aged 6-15 years from West bank and Gaza Strip found that Palestinian children had been exposed to a variety of traumatic events. The most common traumatic events in the Gaza Strip were: watching mutilated bodies and wounded people on TV (82.4%), witnessing bombardment of other homes by airplanes and helicopters (50.8%), and witnessing firing by tanks and heavy artillery on a neighbour's home (34.3%). Similarly children in the West Bank reported commonly the following traumatic events: watching mutilated bodies and wounded people on TV (89.3%), witnessing night raids (72.7%), and witnessing bombardment of other homes by airplanes and helicopters (68%). Eighty-seven (39.2%) of children from the Gaza Strip reported post traumatic stress disorder (40 and above in IES) compared to 51 (34%) of children from the West Bank.
Using SDQ for parents and teachers, 72 children (36.9%) from Gaza were rated as having caseness (were considered as having a problem) by parents using (17-40) cut-off points compared to 44 (29.3%) from the West Bank . Seventy two children (38.5%) from Gaza were rated as having caseness by teachers using (16-40) cut-off points compared to 46 (30.7%) from the West Bank.
Previous studies in the Gaza Strip did not tackle the issue of interventions to help children in overcoming the effect of trauma and violence in the society.
Thabet et al. [17] in a study to evaluate the short-term impact of a group crisis intervention for children aged 9-15 years from five refugee camps in the Gaza Strip during ongoing war conflict.
Children were selected if they reported moderate to severe posttraumatic stress reactions, and were allocated to group intervention (N=47) encouraging expression of experiences and emotions through story telling, drawing, free play and roleplay; education about symptoms (N=22); or no intervention (N=42). Children completed the CPTSD-RI the CDI pre-and postintervention. No significant impact of the group intervention was established on children's posttraumatic or depressive symptoms. Possible explanations of the findings are discussed, including the continuing exposure to trauma and the non-active nature of the intervention.
Other studies tried to elaborate the effect of the other adversities on children mental health such as being orphanage or street children.
Thabet et al. [18] in a study aimed was to establish the level of emotional problems among 115 children aged 9-16 years (average 13.4), who were living in two orphanages in the Gaza Strip. The results showed that children demonstrated high rates of anxiety, depressive, and post-traumatic stress reactions. These mental health problems were strongly inter-related, but were not found to be associated with social/care variables.
Mater et al. [19] in a study aimed to identify the impact of labor on children general mental health and anxiety using Strength and Difficulties Questioner (SDQ)-self report, and Spence Anxiety Scale-self report. The results indicated that 33.9% of children reported hyperactivity; 38% reported emotion problems, 56.3% reported conduct disorder, 79.1% of them had good peer relationships. Mean anxiety score was 48.9. According to Spence Anxiety scale, 20.6% reported obsessive compulsive problems, 18% reported social phobia, 17.7% had generalized anxiety, and 17.7% had panic and agoraphobia, 10.7% had physical injury and 15.3% had separation anxiety.
On September 2005 the Israeli government decided to withdraw from Gaza Strip in a plan was called "engagement plan from one side". Settlers and soldiers pull out of Gaza Strip and the Strip was sealed and left only connection with Egypt through Rafah border.
The last six months of the year 2006, were characterized by the escalation of the crisis right after the capturing of an Israeli soldier by Palestinian militant group in Gaza. Consequently, Israel has started the Summer Rains campaign and imposed strict closure by sealing off the whole Gaza Strip, including; closing Rafah and Karni crossings for prolonged period of times, which resulted in huge humanitarian sufferings for the whole population. Israel has also committed major military offences including a massacre in Beit Hanoun, with over 20 victims. More than 400 people were killed and thousands were injured. The current crisis is can be highlighted by several miseries. The suffering varied between Gaza and the West Bank. Both Gaza and the West Bank suffered from the intensification of Israeli military operations, and the suspension of the transfer of the Palestinian National Autority due which lead to the suspension of civil servants salaries. On the other hand Gaza also suffered from resumption of sonic booms, the shortage of food, fuel and Medical supplies, destruction of Electricity Station. There was also a sharp increase of the state of lawlessness and insecurity and the misuse of weapons, which resulted in bloody clashes between Fatah and Hamas, and resulted in the death of more than 200 people, also, familial clashes and conflicts. This has led to paralysis in civil and governmental institutions, i.e. government services, judiciary, schools, etc.
Thabet et al. [20] in a study after the disengagement plan on September 2005 and withdrawal of Israeli Occupation forces from Gaza Strip aimed to determine the prevalence of PTSD, anxiety, behavioural, and emotional problems of Palestinian children in relation to traumatic events and other socioeconomic status. The results estimated mean traumatic experiences were 7.7. Total IES score of children was significantly associated with PTSD symptoms. No relationships between number of traumatic events and SDQ total or subscales. Prevalence of PTSD in children was 65.5%. The result showed that there were no sex differences in PTSD symptoms. Children coming from families with 4 and less children had more PTSD symptoms. Prevalence of anxiety disorder was (33.9%). No gender differences in anxiety disorder. General mental health problems rated by parents SDQ was (52.2%); conduct disorder (42.2%); hyperactivity (28.1%), emotional problems (32.8%), peers problems (69.9%), and prosocial problems (14%).
Giacaman et al. [21] in study of the influence of exposure to humiliation in war-like conditions on health status in a sample of 3415 students in 10th-and 11th-grades in living in the Ramallah District, West Bank, Occupied Palestinian Territory. Survey questions were derived from the World Health Organization's Health Behaviour in School-aged Children Survey, Gaza Traumatic Event Checklist, and focus group discussions with young people. The results showed that there was a significant association between a high number of subjective health complaints and demographic variables, particularly for females compared with males, and refugee camp dwellers compared with village dwellers. In addition, exposure to humiliation was significantly associated with an increased number of subjective health complaints. Students experiencing three forms of humiliation were found to be 2.5 times more likely to report a high number of subjective health complaints compared with those who had never been exposed to humiliation (52% vs 21%), while those experiencing four forms of humiliation were three times more likely to report a high number of subjective health complaints (62% vs 21%). A multiple logistic regression model revealed that humiliation was significantly associated with a high number of subjective health complaints, even after adjusting for sex, residence and other measures of exposure to violent events. The odds ratio of reporting a high number of subjective health complaints increased as the number of forms of humiliation increased, with values of 1.69, 2.67, 4.43 and 7.49 for reporting a high number of subjective health complaints when exposed to one, two, three or four forms of humiliation, respectively, compared with those who had never been exposed to humiliation.
The last six months of 2006 were characterized by the escalation of the crisis after the capture of an Israeli soldier by a Palestinian militant group in Gaza. Consequently, Israel started the Summer Rains campaign and imposed strict closure by sealing off the entire Gaza Strip. This included closing the Rafah and Karni crossings for prolonged period of times, and resulted in huge humanitarian suffering for the whole Palestinian population. Israel has also committed major military offences including a massacre in Beit Hanoun village in north of Gaza Strip, with over 20 victims. More than 400 people were killed and thousands were injured. The current crisis can be highlighted by several miseries. Though the impact varied between Gaza and the West Bank, both Gaza and the West Bank suffered from the intensification of Israeli military operations, and the suspension of the transfer of the PNA dues which lead to the suspension of civil servants' salaries. Gaza also suffered from resumption of sonic booms, the shortage of food, fuel and Medical supplies, and the destruction of Electricity Station.
There was also a sharp increase of the state of lawlessness, insecurity and the misuse of weapons which resulted in bloody clashes between Fatah and Hamas, and resulted in the death of more than 200 people. There were also familial clashes and conflicts.
This has led to paralysis in civil and governmental institutions, i.e. government services, judiciary, PLC, schools, etc. In early June, 2007, gunfire and rocket propelled grenades could be heard from the streets of Gaza City. In half a year, more than 150 Only essential food and medical supplies would be permitted to enter the Strip and electricity would also be reduced. From that time till today the siege of Gaza was tightened and this was escalated in the last 2 months in which fuel shortage problem and closure of borders became the main issue of discussion in the Gaza Strip.
Due to the current conflict and chaos of the Political situation, few studies emerged in the area to study the effect of factional fighting and siege on Palestinian children and families.
Thabet et al. [22] in study aimed to examine types and severity of traumatic experiences, prevalence of PTSD, depression, and anxiety as a result of the trauma, and differences between trauma, mental health problems and sociodemographic variables. A total of 251 children aged 6-16 were selected from 3 summer camps in August 2007 in the Gaza Strip. Children were interviewed using Gaza Traumatic Events Checklist, IES, CRMAS, and CDI. The results showed that the most common traumatic events due to Israeli aggression reported by children were hearing shelling of the area by artillery, hearing the sonic sounds of jetfighters, watching mutilated bodies on TV, and hearing shootings and bombardment. The most common traumatic events due to factional fighting reported by children were hearing shootings and bombardment due to fighting in the streets, watching mutilated bodies on TV, hearing of the arrest or kidnapping of someone or of a friend. Boys reported more exposure to Israeli aggression than girls, but there was no difference in the level of exposure to factional fighting. There was no difference in the mean number of exposure to traumatic events between young children and older children. Mean IES-8 items was 18.37, intrusion subscale mean was 8.98, avoidance subscale mean was 9.49, 148 children were in the clinical range for post traumatic stress disorder symptoms (59%). The mean anxiety was 13.90, 55 children (21.9%) of children had anxiety. While, mean depression was 18.38, 127 children (50.6%) were depressed. There were no differences in mental health symptoms between boys or girls or younger or older children.
In another study of the impact of siege on Palestinian children mental health and resilience [23][24][25], a sample of 386 children was selected from a community pole from the entire Gaza Strip. The study showed that Palestinian children exposed to mean of 10.18 events due to Israeli aggression and 7.42 events due to factional fighting. No gender differences in reported traumatic events. Posttraumatic stress symptoms mean was 25.94, reexperiencing symptoms mean was 7.50, avoidance symptoms mean was 8.21, and arousal symptoms mean was 7.65. Forty eight 48 children reported probable PTSD (12.4%), 103 children were reported one Criteria (reexperiencing, or avoidance, or hyperarousal) (26.7%), 86 of children reported two criteria-Partial PTSD (22.3%), and 149 chidren had no PTSD symptoms (38.4%). No gender differences in PTSD. Younger age children was significantly reported total posttraumatic stress symptoms than older age children. The results showed that total scores of PTSD were correlated with traumatic events due to Israelis aggression. No significant correlation between trauma due to factional factions and posttraumatic stress symptoms. Mean mental health symptoms mean was 9.05, somatic pains mean was 1.31, depression symptoms mean was 4.36, anxiety mean was 2.21, and fears mean was 1.14. There were no significant differences between boys and girls in total general mental health, somatic pains, anxiety, depression, and fears. Fears were more in younger age children. Children reported mean resilience scores were 58.52, commitment subscale mean was 23.78, control subscale mean was 17.58, and challenging subscale mean was 17.60. There were no significant differences between boys and girls and age of children in total resilience, committment, control, and challenging. The results showed that total scores of resilience were correlated negatively with total PTSD, arousal, and avoidance. Commitment was correlated negatively with arousal, children with better resilience had less PTSD, avoidance, and arousal symptoms and children with commitment had less arousal symptoms. Total scores of resilience were correlated negatively with total mental health, somatic pains, anxiety and fears. Commitment was correlated negatively with anxiety, control was negatively correlated with fears, and challenge was negatively correlated with fears [26].

Conclusion
From the above mentioned data, Palestinian children had been the victims of trauma and violence due to war and conflict and they are at great risk of developing mental health problems such as PTSD, depression, anxiety, hyperactivity, and somatic disorders. Presence of mental health problems were related to severity and continuity of stress and trauma. However, not all children victims of trauma become mentally ill, but more than 50% of them developed sort of reactions which was augmented by other risk factors such as unemployment of the parents, big families, being under siege, restriction of movements, mental health of parents, and community violence [27,28].
Interestingly children were able to cope with such adversities and continue in going to schools and finishing their education to high levels. This resilience outcome denotes the Palestinian children flexibility and ability to look for better future and life.

Case Vignette
Boy age 13 years old, came from family consisted of 8 brothers and 5 sisters. He lost two brothers, one was killed by Israelis and other died at age of 18 of cancer brain. His father is employee and mother finished secondary school and is housewife.
This boy was admitted on 14th June to EL Shifa Hospital-Gaza City after suspicion of appendicitis. Doctors decided to operate him in the same day. On his way to operation room, he witnessed a number injured people coming to the hospital due to factional fighting and he said that he say a man with much blood in his body and tubes all over his body.
The boy said «When they moved me to trolley to take me to the operation theater, I was so afraid and much pain was in my Tommy. I saw a man laying on a bed and blood was covering his clothes. Many tubes were coming from his body. They admitted me to the operation room and two doctors came and they injected me with something and I lost my conscious. Later on, I found me self in my room in the hospital.. I stayed few days and heavy fighting between the factions (Fatah and Hamas) was going on outside the hospital. Sounds of bombing and bullets were so loud.. I was frightened so much. I was discharged from hospital to my home. Few days later, I had severe chest pain, chocking attacks, shorting of breathing, I am not happy and feel not happy, I weep sometimes, with sleep problems, I try to remove the memories from my mind, but I cannot. I had nightmares, I cannot concentrate in my reading and distracted easily. I stopped seeing me friends because I cannot find the words to talk to them. I have fears of going outside the home.. My mother took me to a doctor and he give me medication, I took it for one day and then I had tremors and I stopped this medication. There was no past history of mental illness and no family history of mental illness.
Mental State examination: raveled bizarre behaviour, fears, unable to test reality, distracted, and apathetic. The child was diagnosed PTSD, and was treated by individual psychotherapy and drug therapy using antidepressants (Imipramine 50mg daily and Thiordazine 50mg daily). The child was coming every week. He showed improvement in psychotic symptoms, however his school performance is worsening, other symptoms such as fears, anxiety are less than before.