Psycho Trauma in Children Exposed to the War Atrocities

July-December 2014 Volume 11(2)

Special Article

Unaiza Niaz
Page No:

Special article

 In the memory of the Peshawar School Children’s Massacre by Suicide bombers in December 2014. And a tribute to the pioneering clinical research work on child trauma in Palestine by   Eyad Sarraj, a dedicated psychiatrist and human rights activist, who passed away on 17th December 2013.





Unaiza Niaz


“We owe our children – the most vulnerable citizens in any society – a life free from violence and fear. In order to ensure this, we must be tireless in our efforts not only to attain peace, justice and for countries prosperity, but also for communities and members of the same family. We must address the roots of violence. Only then will we transform the past century’s legacy from a crushing burden into a cautionary lesson “

Nelson Mandela

Since the Second World War, throughout the last six decades there have been wars and conflicts,. For instance, in the 22 countries of the Eastern Mediterranean region of the World Health Organization (WHO), over 80% of the population is either in a conflict situation or has experienced such a situation in the last quarter of century. The twentieth century was marked by violence.  Wars, insurgencies and terrorist attacks have steadily increases over the last few decades The World Health Organization launched the first World report on violence and health on October 3rd, 2002.1 This WHO report  elucidates the different types of violence, from the ‘‘invisible’’ suffering of society’s most vulnerable individuals to the all-too-visible tragedy of societies in conflict regions of the world. It moves forward our analysis of the factors that lead to violence, and the possible responses of different sectors of society Children are the most vulnerable citizens in any society

It is estimated that 2 million children have been killed due to war-related injuries, 4 million have been disabled, 1million orphaned, and 12 million dislocated from their homes (UNICEF, 1996)2.The Durant’s (1968) after writing The History of Civilization concluded that “war is one of the constants in history” and that “in the last 3,421 years of recorded history only 268 have seen no war.”

The year 2005 commemorated the 30th anniversary of the end of the Vietnam War .The year 2005 was significant in understanding the relationship between war and mental health. Daily the media brings the horrors of the ongoing "war" situation in the Eastern Mediterranean region: Palestine, Kashmir, Afghanistan, Syria & the political violence in Iraq. "A generation has grown up knowing only war”.3

 War has a disastrous effect on the health and well being of nations.  War devastates communities and families and often disrupts the development of the social and economic fabric of nations. Death as a result of wars is simply the "tip of the iceberg" Besides the horrors of destruction, human casualties etc, the most serious consequence of war, is the impact on the mental health of the civilian Studies of the general population show a definite increase in the incidence and prevalence of mental disorders. The vulnerable groups are women children, the elderly and the disabled. Women are more affected than men. Although precise figures on the numbers of children and families affected by wars are not known, it has been estimated that in the ten years from 1990 to 2000 over ten million children have been traumatized by war around the world (United Nations,2000).4.


The psychosocial consequences of war and political violence on children and adolescent’s physical and mental health development are well recognized. Several research studies, from different cultures in different war zones around the world, have documented the deleterious effects on the children of exposure to war atrocities. Worldwide, 1 in 6 children lives in a war zone(5

Studies on the effect of war on civilians began after the Second World War, whilst recent studies have focused on contemporary conflicts in the Middle East, South Africa, Ireland and Bosnia, as well as the effect of urban violence targeted at American  children. There is a long history of descriptive reports of children’s psychological reactions to wartime stress in many regions including Cambodia (Realmuto et al., 1992;6. Sack et al., 1995a) 7-Afghanistan (Mghir, Freed, Raskin, & Katon, 1995)(8) South Africa (Dawes et al.,1989, 1990)9,10Bosnia-Hercegovina (Smith etal., 2001)11 Balkans (Ajdukovic, 1998) 12 Zivcic, 1993)13 Kuwait (Nader et al., 1993)14,Palestine (Qouta & El-Sarraj, 2004)15)15 Hawajri, 2003 16

El-Khosondar, 2004),17 Lebanon(Sibai & Sen, 2000) 18and Iraq (Ahmad et al., 2000)(19) Research showed that children living in war zones are at high risk of developing types of psychopathology, predominantly Post-Traumatic Stress Disorders (PTSD) Thabet et al. 2004;20 Husain, 2005;21 Mohlen et al., 2005).


Whilst armed conflicts keep increasing all over the world, children are the ones most affected. There is nothing further immoral in the war than the involvement of children in something they do not understand, they do not choose and they do not have the means to cope with physically or psychologically.. War-affected children very often suffer psychological problems such as depression, post traumatic stress disorder, long term problems in coping with future stressful situations, resentment and hostility


Research works on trauma in children are mostly from Palestine and others from Bosnia and Herzegovina.


Living in war-torn areas is a reality that many people face throughout the world

(Qouta & El-Sarraj, 2004).22 Hundreds of thousands are affected every year, including

the victims of the conflicts, their relatives and friends, disaster workers and eye


When the childhood traumatic experiences are left unexpressed, they can manifest themselves later in life as psychological conditions such as depression, personality disorders or PTSD and maladaptive behavior. Teenagers appear to be the most affected, in contrast with younger children, presenting clinically as PTSD symptoms such as depression, increased fears, nightmares and sleep disorders, psychosomatic symptoms, a sense of helplessness and aggressive behavior 23.  Whereas younger children demonstrate addictive behavior, poor  concentration, hyperactivity, and tantrums 24 ...

In a study by Hasanović et al (2006)25 in Tuzla in Bosnia-Herzegovina  51.6% of children suffered from PTSD, with a greater chance of occurrence in children who had lost one or both parents, while many of the children also had suicidal thoughts.  Husain et al (1998) 26 -in their research study found two thirds of the 521 children who took part in a survey conducted in Sarajevo,had lost at least one parent during war, a figure which collaborates with 61% of Hasanović et al (2006). Moreover, parents who survive often themselves suffer from depression and PTSD, which increases the chance for their children to develop psychopathological problems . 27 Children with psychosocial troubles can develop characteristics that differentiate them from their peers and negatively affect their future reintegration into the new social context after the war  

 Mousa Thabet et al (1999)28.  using self-completed questionnaires, found that the percentage of children from Palestine showing symptoms of PTSD reached 73.2%, while 39% of them reported severe symptoms (18). In a similar study conducted by Espié et al (2009)29 in Gaza and the West Bank, 25.8% of children enrolled met the criteria for PTSD and the factors that were associated more with the appearance of PTSD as they were witnesses of murders or torture, and frequent recipients of threats and the destruction of their property (19). The day raids and bombings of their homes, listening to the sirens and explosions and life in shelters are also associated with high rates of behavioral and emotional problems .


A well designed fairly  recent study aimed to explore the long-term effects of war and occupation on the Palestinian children in the Gaza Strip., was published in 2008 30

 A sample of 1,137 children aged between 10 and 18 years were randomly selected from all parts of the Gaza Strip to participate in the study. The most prevalent types of trauma exposure for Palestinian children were as follows: 99% of children had suffered humiliation (either to themselves or a family member); 97% had been exposed to the sound of explosions/bombs; 85% had witnessed a martyr’s funeral and 84% had witnessed shelling by tanks, artillery, or military planes.

 Notably, this study found that 41% of children suffered from Posttraumatic Stress Disorders (PTSD). Of the 41% of children with PTSD, the levels of symptoms were as follows: 20% (57,606) children suffered from an acute level of PTSD, 22% (67,531) suffered from moderate levels of PTSD, and 58% (180,058) suffered from low levels of PTSD. The children of Palestine form 53.3% (742,200) of the total Palestinian population in the Gaza Strip. The Gaza Strip has a population of (1,400,000) people (the Palestinian Centre of Statistics, 2006) 31

The exposure to long standing traumatic experiences led to an increase in the symptoms of PTSD among Palestinian children in the Gaza Strip. The most prevailing symptoms of PTSD were: cognitive symptoms, from which 25% of children suffered (e.g.,a child might take a long time to get to sleep, or cannot stop thinking about the trauma he/she was exposed to, or feels everything around him was unsafe);emotional symptoms were 22% suffered ( the child feeling alone, feeling sad, fearful ,easily getting tense and nervous, suffering from nightmares and, bedwetting); social behavioral disorders, suffered 22% (eg., aggressive and rude behavior, rejecting a teacher’s or parent’s authority, having difficulty enjoying games and hobbies); academic behavioral disorders, suffered  by 17% (e.g., difficulty in concentrating on study, gradual poor academic performance, difficulties in paying attention during  lessons or  disruptive behavior at school); somatic symptoms, from which 14% suffered (e.g., headaches, stomach-ache, hypochondrias is, somatization).

 Thus there are 305,195 children in the Gaza Strip are in need of urgent psychological, social, and medical services in the areas of prevention, counseling, rehabilitation, and therapeutic treatment. Children from low incomes families suffered more than others. In Gaza, the poverty is very high; nearly 87% of the population lives below the poverty line. This has increased the risk of psycho/social problems in the children of Gaza. The authors concluded that in the current circumstances and the psychological well-being future of Palestinian children is at risk of being compromised by on-going traumatic experiences.

An equally important question that arises is the so-called "cycle of violence." Children who have suffered or witnessed violent episodes often reproduce the violence around them and the parents who have experienced violence also often replicate such violence within the family and community.  Thus as a result, a child who suffers violence within their family can become a carrier of this violence as an adult, creating a vicious circle with consequences that can affect several generations (32). This is termed “Trans- generational Transmission of Trauma”( Transgenerational trauma is a trauma that was transferred from the first generation of survivors that have experienced (or witnessed) it directly in the past to the second and further generations of offspring of the survivors via complex post-traumatic stress disorder mechanisms ) Van der Kolk (2005) 33 has developed the concept of Developmental Trauma Disorder for those experiencing the effects of complex trauma.

 (to be continued in next issue)



2-1996 The State of the World's Children - Unicef

3- Mental health consequences of war: a brief review of research findings R. SRINIVASA MURTHY and RASHMI LAKSHMINARAYANA World Psychiatry,February 2006;5(1):25-30

4-United Nations (2000). What the United Nations does for humanitarian assistance.

5-Rieder M., Choonara I. Armed conflict and child health. Arch Dis Child. 2012;97(1):59-62.)

6 -Realmuto, G., Masten, A., Carole, L., Hubbard, J., Groteluschen, A.,& Chhun, B.(1992). Adolescent survivors of massive childhood trauma in Cambodia: life events and current symptoms. Journal Traumatic Stress, 5,pp.589-599

7-Sack, W., Clarke, G., & Seeley, J. (1995). Posttraumatic stress disorder across two generations of Cambodian refugees. Journal of the American Academy of Child &Adolescent Psychiatry, 34(9), pp. 1160-1166.

8- Mghir, R., Freed, W., Rashin, A., & Katon, W. (1995). Depression and post

traumatic stress disorder among a community sample of adolescent and young adult Afghan refugees. Journal of Nervous and Mental Disease, 183,pp. 24-30.

9- Dawes, A. (1990). The effects of political violence on children: A consideration ofSouth Africa and related studies. International Journal of Psychology, 25,pp.13-31.

10- Dawes, A., & De Villiers, C. (1987). Preparing children and their parents for prison: the wynberg seven. In D. Hanson (Ed.), Mental health in transition. Cape Town: OASSSA Second National Conference Proceedings.

11- Smith, P., Perrin, S., Yule, W., & Rabe-Hesketh, S. (2001). War exposure andmaternal reactions in the psychological adjustment of children from Bosnia-

Hercegovina. Journal of Child Psychology and Psychiatry, 42,pp.395 404

12- Ajdukovic, M. (1998). Displaced adolescents in Croatia, sources of stress and posttraumatic stress. Adolescence, 33, pp. 209-217.

13- Zivcic, I. (1993). Emotional reactions of children to war stress in Croatia. Journal of the American Academy of Child and Adolescent Psychiatry, 32,pp.709-713

14- Nader, K., Pynoos, R., Fairbanks, L., Al-Ajeel, M., & Al-Asfour, A. (1993). Apreliminary study of PTSD and grief among the children of Kuwait following the

Gulf crisis. British Journal of Clinical Psychology, 32,pp.407-416

15- Qouta, S., & El-Sarraj, E. (2004). Prevalence of PTSD among Palestinian children in Gaza Strip. ArabPsyNet Journal, 2, pp. 8-13.

16- Hawajri, A. (2003). Effectiveness of a suggested counseling program to alleviate trauma among the students of basic stage in Gaza Governorate. Unpublished master dissertation, Islamic University, Gaza, Palestine.;

17- El-Khosondar, I. (2004). The effect of rational behaviour therapy in reducing the effect of post-traumatic stress disorder among Palestinian children. Unpublished doctoral dissertation, Ain Shams University, Cairo, Egypt.

18-Sibai, A., & Sen, K. (2000).War and traumatic injury related disability: The need for rehabilitation in the after math of war in Lebanon (1999). This study was part of a larger study funded by the European Commission's INCO-DC Program (1996-1999) in Lebanon and Palestine. IC 18 CT 96 0036. It involved AUB Lebanon, INED France and Cambridge UK .

19- Ahmad, A., Sofi, M., Sundelin-Wahlsten, V., & von Knorring, A.(2000). Post

traumatic stress disorder in children after the military operation "Anfal" in Iraqi

Kurdistan. Eur Child Adolesc Psychiatry ,9, pp. 235–243

20- Thabet AA, Abed Y, Vostanis P (2004)Comorbidity of post-traumatic stress disorder and depression among refugee children during war conflict. J Child Psychol Psychiatry 45:533–542

21- Husain S.A., Nair J., Holcomb W., Reid J.C., Vargas V., Nair S.S. Stress Reactions of Children and Adolescents in War and Siege Conditions. Am J Psychiatry. 1998;155(12):1718

22- Qouta S, Punamaki R, El Sarraj E(2003) Prevalence and determinants of PTSD among Palestinian children exposed to military violence. Eur Child

Adol Psychiatry 12:265–272

23- Burke S. Children and War: Cycles of Violence. In Psych [Internet]. 2006.

24- . Mousa Thabet A.A., Karim K., Vostanis P. Trauma exposure in pre-school children in a war zone. The British Journal of Psychiatry. 2006;188:154-8

25-  Hasanović M., Sinanović O., Selimbašić Z., Pajević I., Avdibegović E. Psychological Disturbances of War-traumatized Children from Different Foster and Family Settings in Bosnia and Herzegovina. Croat Med J. 2006;47(1):85-94

26- Husain S.A., Nair J., Holcomb W., Reid J.C., Vargas V., Nair S.S. Stress Reactions of Children and Adolescents in War and Siege Conditions. Am J Psychiatry. 1998;155(12):1718-

27- Beardslee R., Gladstone T.R.G., Wright E.J., Cooper A.B. A Family-Based Approach to the Prevention of Depressive Symptoms in Children at Risk: Evidence of Parental and Child Change. Pediatrics. 2003;112(2):119-31

28- Mousa Thabet A.A., Vostanis P. Post-traumatic Stress Reactions in Children of War. J Child Psychol Psychiat. 1999;40(3):385-91

29 Espié E., Gaboulaud V., Baubet T., Casas G., Mouchenik J., Yun O., Grais R.F., Moro M.R. Trauma-related psychological disorders among Palestinian children and adults in Gaza and West Bank, 2005-2008. Int J Ment Health Syst. 2009;3(21).

30-Altawil, M., Nel, P.W., Asker, A., Samara, M., & Harrold, D. (2008). The effects of chronic war trauma among Palestinian children. In M. Parsons (Ed.) Children: The invisible victims of war- An interdisciplinary study. Peterborough-England: DSM

Technical Publications Ltd.

31. PCBS [The Palestinian Central Bureau of Statistics] ( 2006). Intifada Statistics -2006, National Palestinian Authority, West Bank-Ramallah: Palestine(

32.-Catani C., Jacob N., Schauer E., Kohila M., Neuner F. Family violence, war, and natural disasters: A study of the effect of extreme stress on children's mental health in Sri Lanka. BMC Psychiatry. 2008;8(33).

.33- Van der Kolk, Bessel A., McFarlane, Alexander C., and Weisaeth, Lars., eds., Traumatic Stress: The Effect of Overwhelming Experience on mind, Body and Society, London: The Guilford Press, 2007.