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A descriptive study of the Psychological symptomatology observed in Palestinian children exposed to military home incursions Treated by MSF Spain in 2010 - 2011 MALCOLM HUGO 1 1 Médecins

Sans Frontières - Spain



MSF Spain has been conducting a mental health programme in the Occupied Palestinian Territories for several years focusing on treating victims of violence related to the ongoing Israeli-Palestinian conflict. The project employs three expatriate psychologists, three local psychosocial workers and one medical officer. A significant number of patients receiving psychological treatment are victims of violent military home incursions,

Although complex PTSD (Post Traumatic Stress Disorder) as a category is not formally recognized in diagnostic systems, it has been suggested.

Complex PTSD better describes the pervasive negative impact of chronic repetitive trauma.

children among them.

Repeated exposure to traumas in the childhood years has been shown to result in a complex symptom presentation which has led to the proposal of the two new diagnostic categories:

Military home incursions are a common occurrence and are often accepted as a way of life in the occupied Palestinian territories.


Complex PTSD


Developmental Trauma disorder

What is Complex Trauma?

The traumatic stress field has adopted the term “complex trauma” to describe the experience of multiple, prolonged developmentally adverse traumatic events occurring in early childhood.

These experiences have multiple, pervasive effects on children’s functionning

Brain Development and Complex Trauma


population: Children receiving psychological treatment from MSF who had experienced military home incursions

Isolated traumatic incidents tend to produce discrete behavioural and biological responses to reminders of the trauma, as seen in the traumatic PTSD diagnosis.

In contrast, repeated traumatisation has a pervasive effect on the mind and brain

Adverse events can alter the organisation of the developing neural system during infancy/childhood.

Psychological Symptoms of Complex Trauma in children

Developmental delay.

 Study design: Retrospective descriptive study

Heightened “fight/flight/freeze” response (eg aggression to self/others, dissociation).

 Data source: Individual patient data entered into the Palestine mission Mental Health Data Base in 2010 - 2011.

Hypervigilance ( to threat)

Emotional dysregulation (hyperactivity, difficult to calm down, stuck in alert).

Sleeping difficulties

Difficulty concentrating

Distrust of others.

Poor social skills/ peer relations.

- Psychological assessments data - Child Trauma Screening Scale Questionnaire (Brewin et al., 2002)

 Study Sample: - 103 children - Age ≤ 15 years; mean age: 11.8 years (SD=3.7) - Gender: 71% male - Victims of military home incursions - Beneficiaries of psychological treatment by MSF in Hebron

Symptoms displayed are not only those characteristic of PTSD but include disturbances in affective and interpersonal self-regulating capacities such as difficulties with anxious arousal, mood regulation, anger management and dissociative symptoms.

Most of this evidence comes from studies of children exposed to sustained or multiple traumas such as emotional, sexual and physical abuse or neglect related to dysfunctional care-giving systems.

The symptomatology observed in this study suggest similar psychological outcomes may occur in children exposed to the effects of longstanding military conflicts.

There is increasing evidence that chronic exposure to traumatic events in the formative years can dysregulate the biological stress system and can lead to changes in brain development and associated impairment in neuropsychological functioning

Due to their still sensitive neurological system, younger children are more susceptible to shocks to their development process. In conflict settings these include experiencing and witnessing violent acts, and the cumulative effects of ongoing disruptions to their care-giving environment.

Many children experience chronic, developmentally adverse traumatic events occurring within their caregiving system in conflict contexts.

Chronically traumatized children, across all ages, have demonstrated deficits in overall cognitive functioning, school performance, and attention/ executive function.

These disturbances in the formative years can lead to impairment in developmental processes related to the maturation of emotion regulation and interpersonal skills development.

Studies have long recognized childhood trauma as a significant risk factor for developing many serious adult mental health disorders). Exposure to repeated traumas in childhood results in not only increased vulnerability to cope with single event traumas, but also qualitative differences in their effects on affective and interpersonal development.

 Limitations: - The lack of a control group to isolate the specific effects of home incursions is a limitation of the study. - Children were not administered cognitive developmental assessments to determine levels of developmental delay.

RESULTS Patients Psychological Symptoms

 52% of the children had experienced more than one home incursion over the preceding years.  >74% presented with persistent sleep disturbances with nightmares.  72,8% presented with anxiety and hyper-vigilance symptoms.  70.9% with excessive fears and persistent feelings of being under threat.  38.8 % presented aggressiveness and irritability.  37.9% presented depressive symptoms  33.9% presented persistent intrusive memories of traumatic events  30% with attention and concentration deficits  28.2% with nocturnal enuresis.  28.2% with avoidance behaviours.  23.3% with somatization symptoms Figure 1. Frequency distributions of Psychological Symptoms (N=103)


Risk of developing Post Traumatic Stress Disorder (from Child Trauma Screening Questionnaire)

>85.7% endorsed more than 6 of the items indicating high risk of developing Post Traumatic Stress Disorder

100% of children experienced intrusive unwanted thoughts about the incursion

90.4% of children presented attention problems

80.9% endorsed feeling distressed about reminders of the incursion, had problems with irritability and controlling their temper and experienced bodily arousal symptoms when reminded of the incursion

71.4% experienced nightmares, sleep difficulties and other hyper-arousal symptoms.

61.9% reported other experiencing and hyper-vigilance symptoms.

This study has not sought to identify the psychological effects resulting directly from home incursions, but to highlight the potential consequences of the added effects these acts can have on an already vulnerable population of children.

It is important to acknowledge the resilience displayed by most Palestinian children.

There is a risk to pathologize the distress and suffering of children resulting from military home incursions with the need to identify the very real risks these incursions can have on children’s psychological development.

The symptomatology observed in this study suggests that similar psychological outcomes may occur in other children exposed to the effects of longstanding military occupation.

Given the evidence that complex trauma is associated with structural and functional alterations in brain development, the need for further longitudinal research and implications on treatment methodologies is discussed.

Psychological symptomatology seen in Palestinian children exposed to military home incursions  

Research by Malcolm Hugo