Stress, Trauma, Mental Health and Ways of Intervention of Palestinians in the Gaza Strip

For the last few decades, Palestinians living in the Gaza Strip and West Bank have been exposed to a variety of stressful situations, including imprisonment, beating, house demolition, killing, and constant social and economic pressure. Such stressful conditions dramatically increased because of continuing social and economic control, land seizures and an ‘iron fist’ response to all forms of dissent, i.e. the first period of 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 stone-throwing 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 long-lasting consequences for the entire Palestinian population and its purpose to end the military occupation.

Political violence due to al aqsa intifada

On September 2000, the Al Aqsa Itifada erupted. Within the first 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 [1].

Politic violence due to unilateral disengagement in the gaza strip

The most notable development in this year (2005) was the unilateral Disengagement Plan implemented in the Gaza Strip by the Israeli government. In September 2005, IOF dismantled all Israeli settlements in the Gaza Strip (21 settlements). This development in itself constituted a positive development, particularly in the Gaza Strip, where the positioning of settlements, and the associated IOF military network, on more than 40% of its land came to an end. The implementation of the Disengagement Plan was accompanied by unprecedented restrictions on movement between the Gaza Strip and the outside world. All border crossings, including Rafah International Crossing Point, the sole outlet of the Gaza Strip to the outside world, were closed for 80 days, beginning on 7 September 2005. On 15 November 2005, the Palestinian and Israeli sides reached an agreement regarding the border crossings of the Gaza Strip, according to which Rafah International Crossing Point was reopened on 25 November 2005. Although restrictions on the movement of Palestinians between the Gaza Strip and the outside world were eased, the agreement maintained effective control of IOF over the crossing point and the movement of persons and goods between the West Bank and the Gaza Strip. As result, thousands of Palestinian families are deprived of possibility of seeing each other.

Political violence after palestinian council election

Since the beginning of 2006, the situation in the Gaza Strip had become more uncertain and only can be viewed with concern by international organizations working in the West Bank and Gaza Strip. Specifically, this uncertainty is based on the results of the Palestinian Legislative Council elections at the end of January 2006, in which the Islamic Resistance Movement (Hamas) won 74 of the 132 seats. Following this election, the international community, through public statements issued by the Quartet for the Gaza Disengagement, the United Nations (UN) and the European Union (EU) asked the future Hamas-led government to commit to non-violence, to the recognition of Israel and to the acceptance of previous obligations (the Roadmap) in order to allow international donors to continue providing funds to the PA. Israel has announced that it will withhold monthly tax payments to the PA, amounting to between US$ 50 million and US$ 65million per month and constituting about two-thirds of the income derived from Palestinian economic activity [2].

Political violence due to gaza siege

In July 2008 another historical period started when Israel and Palestinian factions agreed on truce period for 6 month ending in 19th December 2008. During this period at the least 22 Palestinians were killed in Gaza Strip and tens were wounded, locally made rocket continued to shell the near Israelis towns close to Gaza Strip border [3]. On 19th December the Palestinian fighting factions decided not to prolong the truce for another period and started shelling the Israelis areas with locally mad rockets, Israelis voices inside the minister cabinet and streets started to increase to take military action against the Gaza Strip beside the siege measures which already present for the last 18 months. In the last 2 weeks, the humanitarian condition of the entire Gaza Strip entered into a very serious stage in which most of the bakeries stop working and cues of people are in front of the opened one, electricity is coming for 6 hours daily, no house gas and people started to use woods and kerosene cookers. Besides, there was a shortage in most of food material and UNRWA stopped distribution of food for around one million persons in the Gaza Strip [3]. During the last few years of siege, Palestinian families in the Gaza Strip were exposed to a variety of stressors and traumatic events due to Israelis violence including incursion, bombardment, shelling of the area, and closure of the borders which had very negative impact on psychological wellbeing.

Political violence due to war on Gaza 2008-2009

On 27 December, 2008, the Israeli occupying forces conducted sudden and intensive air strikes on Gaza Strip. The attacks began at approximately 11:30 am and lasted for approximately three hours. These attacks destroyed most of the Gaza security offices including police stations. As a result, more than 230 Palestinians were killed and at least 770 were injured including 100 in critical condition. This military operation continued for 23 days. As a result, 1320 Palestinians, including 446 children and 110 women and 108 elderly, were killed and 5320 others, including 1855 children and 795 women, were injured. This doesn’t mean that the rest of the fatalities and injuries were engaged in hostilities, or that they are not innocent civilians. A large number of men and male youth were killed in their homes, in the presence of their families. Its phases resulted in a mass destruction of private properties. At least 4000 houses were totally destroyed and other 16000 houses were partially damaged [4].

Political violence due to 8 days war on gaza on 2012

On 15^th November 2012 another cycle of Israeli violence started by assassination of the commander of Al Qasam Brigade in Gaza (Ahmaed El Jaabari). Israel Military Forces bombarded Gaza Strip by air, ground, and sea rockets for 8 days, and the Palestinian military factions stroke back locally made rockets on the border towns in Israel and into the inside cities of Israel. Following eight days of violence on Gaza from November 14 to 21 November, a cease-fire agreement was declared effective on 9:00pm, November 21, 2012. The latest cumulative casualty figures reported by the Ministry of Health (MoH, 2012) in Gaza were 175 killed persons (151 males; 24 females) of whom 43 (25%) were children; 16 children were less than 5 years old. The total includes 5 persons who had later died of their injuries, and 1399 persons injured, of whom 431 (34%) were children and 141 were less than 5 years old. (Earlier MoH data with gender disaggregation was based on uncorrected figures of 1404 injured (994 males; 410 females).

Political violence due to 51 days war on gaza on august 2014

The last war on Gaza Strip was in August 2014, it is considered the most destructive one in comparison with two previous wars, which lasted for 51 day. This war caused killing 2,145 Palestinians, 578 of them were children and adolescents, about 11,000 others had been wounded, more than 500,000 Palestinians internally displaced at the height of the hostilities, Over 100,000 still displaced, and approximately 18,000 housing units destroyed or severely damaged OCHA 2014.

Psychosocial impact of political violence due to wars and stressors of siege on palestinians

Traumatic experiences and political violence had adverse effect the Palestinians well-being and increased rate of psychosocial problems. Beside trauma and violence, other risk factors emerged from previous studies in the field such as being a boy, having previous history of mental health problems, comorbidity of other psychiatric disorders, low family income, absence of family and community support, high unemployment level in the last few years, increase number of family members, and overcrowding due to poverty [5-8].

All of the above mentioned risk factors may lead to more mental health problems like post-traumatic stress disorder, anxiety, depression, ADHD, conduct, and substance abuse. In this paper we are going to revise some of the studies conducted in this field for the last decade, which had investigated the effect of trauma and political violence on children and families psychosocial wellbeing, their consequences, and evolving interventions to improve children’s and families’ mental health.

Considering that our area is very volatile politically and changes in political situation is very quick, so presentation of violence, trauma, impact on children and families also change from time to time. This includes changing in risk and protective factors and also mediating factors between the violence and final outcome such as psychosocial problems. Also, reviewing our previous work in the field shoed that severity of violence is changing from time to time, while types of traumatic experiences are similar including the watching mutilated bodies in the TV, hearing and seeing the shelling of the area, exposure to sonic bombs, and witnessing home bombardment and demolition. Types of trauma was changing during the first Intifada from tear gas inhalation, witnessing day and night raids by the soldiers, arresting of family members, and beating of relatives [6,9].

However, during Alqsa Intifada from 1999-2006 political violence and types of traumatic experiences of Palestinian changed again due to use of excessive forces to overcome the Palestinian demonstrations, and as a results children and families experienced other types of traumatic events such as being injured by rockets and bullets, witnessing home demolition and destruction, shelling of the area, hearing the sound of jetfighters. While, other traumatic events such as witnessing mutilated bodies and injured people of TV were continued to be on the top list of such traumatic events [8,10-13].

After the one side disengagement of the Israel from Gaza Strip on 2005 and escalation of the situation on the border, new Israeli measures were inflicted on Gaza Strip such as siege, repeated incursion of the area with more intense violence and traumatic events. Almost all the residents of Gaza Strip were experienced hearing shelling of the area by heavy artillery, bombardment by tanks and airplanes, beside the other traumatic events such as witnessing mutilated bodies and injured people on TV [6].

On January 2009, a new chapter of the conflict was opened after the 23 days of War on Gaza. However watching mutilated bodies in the TV was less than previous studies due to shortage of electricity in the first ten days of the war and later on. Such traumatic events had short and long-term effect on children and families psychosocial wellbeing. Most of the previous studies investigated the negative impact of trauma on mental health of children and families. Psychological reactions ranged from simple phobia to more severe mental health disorders including PTSD, depression, anxiety, ADHD, and substance abuse. Variety of studies in the area used standardized measures to evaluate the effect of traumatic events on children and families. Such measures used to investigate the reactions to trauma, while others investigate the mental health disorders. In the following review we will highlight the most common psychological reactions.

Previous studies showed that PTSD is not the only reaction to trauma, but children reported depression, anxiety, and ADHD symptoms.Vostanis [5] in a study of social adversities and anxiety disorders in Palestinian children showed that 21.5% of children showed anxiety problems. Anxiety disorders varied from study to study according to the type of traumatic event and sample size.

After the establishment of the Palestinian Authority according to Oslo accord, there were few years of peace and stability in the area. However, psychological reactions due to first Intifada was evaluated by [9] in study of children aged 7 to 12 years, who had experienced war conflict, children who reported moderate to severe PTSD reactions 40.6%. However, in following the same children during the peace process with the same instruments used previously showed that PTSD was dropped to 10% Thabet [6].

At the end of 1999, the Al Aqsa intifada was erupted and researchers tried to find the impact of such event on Palestinian children. In a comparative study of 91 children exposed to home bombardment and demolition and forced displacement to other areas during Al Aqsa Intifada and a 89 control group, who had been exposed to other types of traumatic events, [7] found that among children who had lost their homes due to bombardment, 54 (59.3%) had severe to very severe PTSD reactions, i.e. above the cut-off score of 40 for likely clinical range, compared to 22 (24.7%) of the control group, 35 (39.3%) of non-exposed children were within the likely clinical range of anxiety disorder, and 20 (22.0%) of the exposed children. Other researchers such as Quota et al (2003) in study the prevalence and determinants of PTSD among 121 Palestinian children (6-16 years; 45% girls and 55% boys) living in the area of bombardment, showed that 54% of the children suffered from severe, 33.5 % from moderate and 11 % from mild and doubtful levels of PTSD. Girls were more vulnerable; 58% of them suffered from severe PTSD, and none scored on the mild or doubtful levels of PTSD. Similar rates of PTSD were found in other studies, Abed Y et al. [8] in study 403 Palestinian refugee children showed that the average child endorsed an average of four traumatic events. Adopting previously established cut-offs, 21.1% of children reported symptoms that could be defined as likely mild PTSD reactions, 52.6% moderate, 22.9% severe PTSD, and 1.0% as very severe PTSD reactions.

This rate of PTSD was also reported in study of El Helou M et al. [10] of 349 children aged 6-15 years from West Bank and Gaza Strip which found that 39.2% of children from the Gaza Strip reported post traumatic stress disorder compared to 34% of children from the West Bank. Besides PTSD, others investigated the effect of political violence on children general mental health [10]. In study of 349 children aged 6-15 years from West Bank and Gaza Strip using strengths and difficulties questionnaire found that 36.9% of children from Gaza were rated as having caseness (were considered as having a problem) by parents compared 29.3% from the West Bank and 38.5% of children from Gaza were rated as having caseness by teachers using compared to 30.7%of children from the West Bank.

Also, Zakrison et al. [14] in study to determine the prevalence of psychological morbidity among Palestinian children living in the southern Bethlehem District of the West Bank during July 2000. This study has demonstrated a high prevalence (42.3%) of psychological morbidity among children in the West Bank during the summer of 2000. The overall prevalence of mental health disorders, determined using the Rutter A2 scale, in the West Bank is greater than two times higher than the last reported rate of “caseness” in the Gaza Strip

Other studies found higher rates of post-traumatic stress reactions, Elbedour et al. [13] in study of 229 Palestinian adolescents living in refugee camps of Rafah and Khan-Younis in the southern region of the Gaza Strip, found that 68.9% of the sample was classified as having developed PTSD, 40% of the participants reported moderate or severe levels of depression. [15] in study with 409 children and young people aged 9-18 years in the Gaza Strip during continuing exposure to political trauma during the last incursion of the Gaza Strip on summer of 2006. The study showed that 65.5% of children were rated within the clinical PTSD range. However, there were no significant gender differences on PTSD scores. Also, 25.4% children reported anxiety scores within the clinical range. There were gender differences on RCMAS scores toward girls. Using the Strengths and Difficulties Questionnaire on general morbidity (behavioural and emotional problems), 203 children (49.6%) were rated within the likely clinical range.

[16] in another study of sample of 197 children aged 9-18 years in the Gaza Strip, in areas under ongoing shelling and other acts of military violence. The results showed that 138 children out of 197 (70.1%) were likely to present with PTSD, 33.9% were rated as having anxiety symptoms of likely clinical significance, 42.7% were rated as having significant mental health morbidity by their parents. During the last 10 years of siege, Palestinian children and their families in the Gaza Strip were exposed to a variety traumatic events due to Israelis violence including incursion, bombardment, shelling of the area, In study of the impact of siege on Palestinian children mental health and resilience [17], A sample of 386 children was selected from a community pole from the entire Gaza Strip. The study showed that 38.4% of chidren had no PTSD symptoms, 26.7% of children reported one criteria (reexperiencing, or avoidance, or hyperarousal), 22.3% of children reported two criteria-Partial PTSD, and. 12.4% of children reported full criteria of PTSD.

Later on after 20 months, children of Gaza Strip were evaluated to find the long term effect of war on Gaza, [18] in study a sample consisted of 449 children from Gaza Strip, 29.8% of children had no PTSD symptoms, 28.3% had at least one cluster of symptoms (intrusion or avoidance or hyperarousal), 30.5% had partial PTSD (Two cluster of symptoms), and 11.4% had full criteria of PTSD. No significant sex differences in PTSD. Using cut-off point of RCMAS, 20.5% of children scored above cut-off point of anxiety. The results showed 22.3% of children scored above cut-off point of Birleson Depression scale. Effect of war on Gaza (2008-2009) was investigated after two weeks of the war, [19] in study of 374 Palestinian children aged 6-17 years old. The results showed that only 1.3% of children showed no PTS reactions, 7.2% reported mild PTSD reactions, 29.9% showed moderate PTS reactions, and 61.5% showed severe to very severe PTS reactions [20] .Trauma exposure was significantly associated with PTS reactions. No sex differences in reporting trauma or PTS reactions.

Thabet S [21] in study aimed to describe the range of acute traumatic stress disorder symptoms in a sample of displaced and non-displaced children and adolescents in the Gaza Strip war on Gaza (2014). The study sample consisted of 381 children and adolescents ranging in age from 7 to 18 years. The highest frequencies of reported traumatic events for both groups (displaced and non-displaced) were hearing shelling of the area, hearing the loud voice of Drones, and watching mutilated bodies in TV. However, displaced children reported more traumatic event such as forced to leave home with family members due to shelling, receiving pamphlets from Airplane to leave home at the border area to the city centre, threatened by telephone to leave their homes for bombardment of homes, destruction of their personal belongings during incursion.

Displaced children reported more traumatic events than nondisplaced ones. Boys reported more traumatic events. Using the DSM-V criteria, 10.0% of non-displaced children and 18.4% of displaced children had acute traumatic stress disorder. Displaced children reported more acute stress disorder, dissociative, reexperiencing, avoidance, and hyperarousal symptoms. Traumatic events were associated acute traumatic stress, re-experiencing, and hyperarousal symptoms [22]. In study investigated the relationships between stressor due to restriction of Palestinian movement, traumatic events due to war on Gaza and psychological symptoms, quality of life, and resilience. A sample consisted of 502 randomly selected subjects from 5 areas of the Gaza Strip. Measures for collecting data include Stressful Situations due to Siege Scale, Gaza Traumatic Events Checklist, Brief Symptom Checklist-BSI-19, World Health Organization Quality of Life, and Resilience scale. The results showed that the most common stressful situations due siege were: feelings of being living in a big prison cannot finish some construction and repair work in their house due to shortage of cement and building materials, prices were sharply increased in the last few years. Participants commonly reported traumatic events such as hearing shelling of the area by artillery, hearing the sonic sounds of the jetfighters, hearing the loud voice of drones, and watching mutilated bodies in TV. Males had significantly experienced severe traumatic events than females. People live in cities reported more traumatic events than those live in a village or a camp. As a reaction to stress and trauma Palestinians participants reported anxiety symptoms such as nervousness or shakiness inside, feeling tense or keyed up; while depression symptoms reported were feeling sad, and weak in parts of their body. However, feelings of worthlessness and thoughts of ending life were seldom. Females reported less stress and trauma, but they showed anxiety and somatization symptoms than males. Only 12.5% said that they evaluate their life as good, and 27.1% said they enjoy their life. Better quality of life is an indicator of wellbeing; females had higher level of quality of life. While, physical health activities of daily living were more in males was. Palestinians used religious ways of coping with the stress and trauma, and 98% said God is helping all the time, they were proud of their achievements, and had strong sense of purpose in their life.

There were statistically significant positive relationship between stress due to the siege and closure and traumatic events, psychological symptoms, depression, somatization, and anxiety. However, there was statistically significant negative relationship between total score of stress due to the siege and closure and the total resilience factor and subscales, and quality of life. Total traumatic events were positively correlated with psychological symptoms, depression, somatization, and anxiety [23]. In study investigated the effect of traumatic events due to eight days of military escalation on children PTSD, anxiety, resilience, relationship of between children mental health problems and resilience. The study sample consisted of 502 randomly selected children from 16 districts of the Gaza Strip. Age ranged from 9 to 16 years. Results showed that children reported commonly traumatic events such as hearing the loud voice of Drones (98.8%), hearing shelling of the area by artillery (98.6%), hearing the sonic sounds of the jetfighters (98.4%), and watching mutilated bodies of Palestinians in TV (98.2%). Mean traumatic events reported by children was 7 events. Boys reported severe traumatic events than girls; traumatic events were reported in children living in a city than in village and camp. This study showed that 35.9% of children showed full criteria of PTSD. Post traumatic stress disorder and reexperiencing symptoms were more in girls. Also, children coming from families with family income less than $300 and living in city the children anxiety symptoms, 30.9% of children had anxiety disorder. No differences in anxiety disorder between boys and girls. Anxiety was more in children living in camps and family monthly income less than $300.

Al Sheikh [24] in study aimed to find the relationship between trauma due to war and post traumatic stress disorder, social, and family support among adolescent in the Gaza Strip. The sample consisted of 400 students (200 boys and 200 girls). The study showed that mean traumatic experiences reported was 12.19. Boys had been exposed more than girls. The study showed that 25% of adolescents reported partial PTSD and 9.3% had full criteria of PTSD. Boys reported more PTSD than girls. Mean of social support was 83. Adolescents aged 13 years had less total social support than the older group. Mean of family support was 97.33, acquiring social support was 28.62, reframing was 26.18, seeking spiritual support was 14.26, mobilizing family to acquire and accept help was 12.48, positive appraisal was 12.75. There was positive correlation between total traumatic events and PTSD, intrusion, and avoidance. While total traumatic events were correlated negatively with family coping and social support. There was positive correlation between PTSD and social support, and family support [25].

In a study aimed is to determine the relationship between traumatic experience, posttraumatic stress disorder, resilience, and posttraumatic growth among adolescents in Gaza Strip. The sample consisted of 400 secondary school students (200 males and 200 females) from the seven directorates of the Gaza Strip Their age ranged between 15-18 years with mean age 16.67 years. The results showed that the most common traumatic events were hearing the voices of the bombing on different areas (92.3%), listening to the sound of drones constantly (86.3%), and hearing the death of a friend or neighbour during the war (79.5%), and 13% of adolescents had mild trauma, 39.8% had moderate trauma, and 47.3% had severe trauma. Also, the results showed that 24% adolescents had partial PTSD, and 10.5% had full criteria of PTSD. The results also showed that adolescents had above moderate level of resilience with mean score 80.48, and there were no significant differences in resilience levels related to gender, age, family size, family income, fathers’ job and level of education, but adolescents from Khan Younis and Rafah had higher resilience compared to their counterparts from other places.

The results showed that the mean of total post traumatic growth was 46.05, appreciation of life 6.54 , spiritual change 5.25 , personal strength 8.04 , relating to others 15.30 , new possibilities 10.86 , and there was higher level of posttraumatic growth in adolescents aged 15-16 years old had. The results showed that there was statistically significant positive relationship between total traumatic events due to war and PTSD and negative correlation with PTG and resilience. PTSD was negatively correlated with resilience. Finally, PTG was positively correlated with resilience.

Al Galini [26], in the study aimed to investigate the relationship between war trauma and anxiety and post-traumatic stress disorder among preschool children in Gaza Strip. The sample consisted of 399 preschool children mothers of preschool children who were enrolled in kindergartens in the five areas of Gaza Strip. The most commonly reported traumatic experiences by mothers on behalf of their children were: hearing shelling of the area by artillery (95.5%), hearing the loud voice of drones (89.2%), and watching mutilated bodies in TV (81.2%). Mean traumatic experiences by preschool children were 8.3. The prevalence of PTSD was 6%. PTSD scores were higher among children age 5 and more years. Preschool anxiety scales showed that the mean for total anxiety scale was 49.84, generalized anxiety was 10.7, social anxiety was 8.4; specific phobia was 21.11, and separation anxiety was 9.65. The results showed that there were significant association between trauma and total PTSD and anxiety, as well a significant association between PTSD and anxiety.

Thabet et al. [27] in a study aimed to find the prevalence rate of PTSD, anxiety and depression among orphaned children in Gaza Strip. The study sample consisted of 81 orphaned children from Al-Amal Institute for Orphans. The minimum age was 9 years and the maximum age was 18 years, Mean=13.34 years. The mean post-traumatic stress disorder was 35.79, intrusion symptoms was 19.77, avoidance symptoms was 14.30 and mean arousal symptoms was 13.65, 55.6% of orphaned children showed moderate and 34.6% showed severe PTSD. Girls reported significantly more PTSD, avoidance, and arousal symptoms than boys. A child living in a city had more PTSD than those children live in a camp or a village. The study showed that 67.9% showed depression. Depression was more in children from north Gaza had more depression than those coming from the other four areas of the Gaza Strip. The results showed that 30.9% of children rated as anxiety cases. Children 13-15 years old had more anxiety than that younger and older age than them and children coming from north Gaza had more anxiety than those coming from the other four areas of the Gaza Strip. The result showed that there was positive correlation with statistical significance between depression and anxiety, intrusion, and avoidance. While, total depression was negatively correlated with arousal symptoms of PTSD. Anxiety was negatively correlated with PTSD and avoidance symptoms of PTSD [28]. In study aimed to find the most common stressors facing the adolescents in the Gaza Strip, to explore the types and severity of the traumatic experiences, and to estimate the prevalence rate of post traumatic events. Method: The target population consisted of 319 adolescents ages 12 to 18 years with mean age of 14.97 (SD=2.01). They were 163 boys (51.1%) and 156 girls (48.9%). Adolescents were interviewed with Life Events Checklist, Traumatic Events Checklist, and Posttraumatic Stress Disorder Reaction Index.

The study showed that 58.3% reported life stressors, mean stressors was 4.07. Boys significantly reported more life stressors than girls. Mean traumatic events reported was 3.7. Boys report more traumatic events than girls. The study results showed that 29.5% had partial post traumatic stress disorder and 23.5% had full criteria of post traumatic stress disorder. Total stressors and traumatic events reported by children were strongly correlated, stressors were correlated to total with post traumatic stress disorder, and re-experiencing, total stressors were strongly correlated with re experiencing, numbness, hyperarousal, and dissociative symptoms. Also total traumatic events total were strongly correlated with post traumatic stress disorder, re-experiencing, avoidance, numbness, hyperarousal, and dissociative symptoms Bessiso [29].

In a study aimed to investigate the relationship between stressors due to siege, war trauma, anxiety and depression among cancer patients in Gaza Strip. The study sample consisted of 380 cancer patients (128 male and 252 female). The most common reported stressors due to siege were : 92.9% said prices are sharply increased due to closure, 90.3% said they feel that they are in big prison , 85.5% their work affected so much due to cut-off of electricity and shortage of gas (85.5%). The patients with cancer reported from 2-16 stressors due to siege with mean 9.02. Male cancer patients reported more stressors due to siege and families with low income had more stressors. Twenty four percent of patients had severe depression, female patients, and families with monthly income less than $ 300 had more depression. The results showed that 58.9% of patients had severe anxiety; female patients had more anxiety and families less than $ 300 had more anxiety. The study showed that there were statistically significant positive relationship between total stressors due to siege and depression symptoms and anxiety and there were significant relationship between the depression and anxiety in patients with cancer.

There has been limited research on the effectiveness of specific psychological interventions for children living in war zones. However, a number of studies have described or evaluated different models of interventions for mental health problems among children who had suffered abuse, experienced natural disasters, political, or exposed to community violence. These predominantly adopt psychodynamic or cognitive therapeutic frameworks, and a variety of techniques, with the broad aim of enabling the child to make links between trauma, emotions and beliefs, which can subsequently be challenged and modified. These have been designed for the classroom, the family, the individual child, or a group of children exposed to similar events.

Vostanis [5] in a study aimed 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. The results showed 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 [6]. In a study of 304 schoolchildren aged 6-16; the results showed that there was statistically significant decrease in total scores of child mental health and hyperactivity symptoms after student school mediation program. According to parents, the results showed that there was statistically significant decrease in obsessive and overanxious symptoms after student mediation program. Abed Y et al. [7] in a study aimed to evaluate the schoolbased debriefing sessions for children living in a zone of ongoing war conflict. A randomly selected sample of 240 children aged 10- 16 years who were affected by the current conflict in the Gaza Strip were interviewed about their war experiences and reactions to the violence before and after participating in the 2-week intervention in schools for 8 sessions. The sessions aimed at facilitating communication, discussion of fears, myths and beliefs, discharge of feelings, and empowerment in building their future. Drawing, storytelling, and role-play were used. Children themselves reported decrease in all mental health problems after the intervention. However parents disagreed with their children and reported no change in behavioural and emotional problems of their children after the intervention.

The study findings that using school based counselling setting in time of war and trauma could improve children mental health if they report their feelings themselves and not their parents. This highlight the need for more long acting and new methods of intervention for children living in area of war and conflict such as cognitive behaviour therapy and social skills training to enable children cope with trauma and stress. Also, [8] in study of 84 school adolescents aged 12-17 to find the efficacy of psychodrama sessions on children victims of trauma and war in the Gaza Strip found that there was statistically significant decrease in total scores of child mental health problems and hyperactivity symptoms after psychodrama program. According to parents, the results showed that there was statistically significant decrease in obsessive and overanxious symptoms after student the intervention program. However, teachers did not report improvement in most of adolescent’s mental health problems. Parents and adolescents agreed that the program improved the adolescent’s mental health. However, teachers said no effect.

After War on Gaza another study was conducted to study the effectiveness counselling settings in reduction of the emotional reactions and psychological violence among children in the Gaza Strip after being subjected to psychological trauma resulting from the war on Gaza. In a sample study of 76 children, including 38 from the experimental group and 38 control group. The age ranged from 6 to 15 years and average age was. The study found that there was no statistically significant difference between the two phases after the intervention, which lasted for two weeks and included many activities that may help children overcome the psychological reactions of the total post-traumatic stress, and symptoms after a traumatic event. Later one, Vostanis P [9] in study of total number of 108 children from four schools in the Gaza city, to investigate the efficacy of expressive writing as a therapy for children affected by war and trauma The results showed that showed there were statistically significant differences in mean of post traumatic stress reaction toward the post therapy period, adolescents reported more post traumatic stress reactions after the therapy, but subscales such intrusion and avoidance remain unchanged. No significant changed in level of depression after the intervention. However, level of anxiety decreased after the intervention.

Our previous review showed that Palestinian children and families in the Gaza Strip were victims of continuous trauma and war ranging from direct occupation to siege, recurrent incursions, and lastly War on Gaza. Such traumatic experiences due to war increase the risk factors for developing psychosocial problems such as anxiety, depression, PTSD, and other mental health problems. Psychological reactions of children to trauma included Post traumatic stress reactions which ranged from 10% to 71 %, anxiety disorders from 21-34%, and depression rate reached 40%.

However, few studies had been conducted to evaluate the effectiveness of different types of psychological interventions in schools and community centres in the Gaza Strip. Some of these intervention methods improved children mental health such as psychodrama, expressive writing therapy, while others did not improve much mental health. This highlights the needs for more controlled studies and other ways of intervention such as using cognitive behaviour intervention, long-term involvement of parents and teachers and also longitudinal studies to evaluate the long term effect of trauma on children and families.

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