PTSD in Palestinian Children: cultural and treatment issues

Dr. Fadel Abu Hein, PhD Clinical Psychology Associate Professor ,Al-Aqsa University , Gaza ,Palestine

Protective cultural influences in relation to PTSD

Culture has been defined by sociologists and anthropologists in different ways. Most would agree that it refers to a number of collective factors. These include patterns of behaviour and customs, values, beliefs and attitudes, implicit rules of conduct, patterns of family and social organisation, and taboos and sanctions. These are shared by a group of people that have a common identity, based on ethnic and sometimes territorial unity. One grows up, in a very general sense, thinking, believing and behaving in ways which are found in ones culture, adhering to its rules and conforming with its practices. Cultures vary in the degree to which rules and customs are followed rigidly, and in how pervasive its influence is on the individuals life (de Silva, 1999).

Family and social support is often difficult to distinguish from underlying cultural factors. Cultural differences are evident in the responses of children

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to traumatic events and the presentation of child psychopathology. In a study of South Asian refugee children who settled in Australia, South Asian

children showed higher rates of somatoform symptoms than in the native Australian child population (Krupinski, 1986).

Similar physical presentations of distress have been found in other nonwestern traumatized populations such as Lebanese children, 58% of whom suffered from psychosomatic disorders four years after the Israeli invasion of Lebanon in 1982 (Rayhida et al, 1986). Farhood et al (1993) found high rates of somatisation among Lebanese children and parents.

Also, Palestinian children in the West Bank were found to predominantly suffer from conduct and psychosomatic problems (Baker, 1990). The same study showed that, conduct and psychosomatic problems among children were more severe within the refugee camps, than in urban or rural areas. In another study of Palestinian children living in the Gaza Strip exposed to traumatic events during the Intifada, Abu Hein et al (1993) found that 25% had conversion fits. This presentation applied to both children and adults.

Cambodian adolescent refugees in the USA were likely to continue to feel guilty about abandoning their homeland, have unfulfilled obligations to death, be haunted by painful memories, or have impaired concentration (Eisenbruch,

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1991). The author pointed out that Cambodian adolescents in Australia, where there was less pressure to conform and where they were able to attend some traditional ceremonies, were better adapted than those in the USA. There have been studies of parental perceptions of child mental health problems across different cultures. In a study of Vietnamese parental perceptions of child and adolescent mental illness, parents identified psychotic symptoms, disorientation, and suicidal thoughts and behaviours as

psychopathological. They perceived biological/chemical imbalance, traumatic experiences, and metaphysical/ spiritual imbalance, as the most likely causes of child mental illness (McCarty et al, 1999).

The role of culture in the development and outcome of post traumatic stress disorder has been discussed. As the diagnostic category for PSTD is relatively new, there is only a limited literature addressing cultural aspects of this disorder, unlike disorders such as schizophrenia and depression. However, it is clear that cultural factors have an important role to play in the genesis and presentation of PTSD, and in how it is perceived, responded to and treated.

From the above studies, we can conclude that cultural factors can modulate the type of mental health symptoms, with higher rates of somatoform and somatising symptoms in certain cultural groups. Individuals in Eastern countries are more likely to express psychological problems through somatic symptoms like headaches, abdominal pains, and conversion fits (Rayhida et

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al, 1986; Baker, 1991; Eisenbruch, 1991; Abu Hein, 1993; McCarty et al, 1999).

Therapeutic considerations in PTSD

Despite the notable increase in the quantity and quality of empirical research in the area of trauma and PTSD in recent years, there have been few rigorous studies of treatment outcome with this population. A variety of modalities have been presented in descriptive papers, including individual, family, group, behaviour and self-inoculation therapy, as well as psychopharmacological treatment (Pefferbaurm, 1997). Unfortunately, there has been limited evidence of the effectiveness of various treatment interventions, or the comparative advantages and specificity of therapeutic modalities.

Pynoos and Nader (1988) described a psychological first aid approach for children exposed to community violence, which may be offered in schools as well as in traditional treatment settings. This model is based on clarifying traumatic event, normalizing children's PTSD reactions, encouraging

expression of feelings, teaching problem-solving techniques, and referring the most symptomatic children for ongoing specialist treatment. Individual therapy begins with a sensitive clinical interview. The desire to avoid reminders of the trauma commonly dampens the childs verbal expression. Terr (1989)

maintains that play therapy has benefits even without interpretation, as over

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interpretation may confuse the child. She does not, however, discourage the sense of mastery.

Galante and Foa (1986) evaluated a school-based group therapy for high risk Italian children victims of a devastating earthquake. Children were evaluated at 6 and 18 months post-earthquake. The children who had received the treatment showed a significant drop in PTSD symptoms.

Group therapy and support groups could be used in children exposed to traumatic event on a large scale. Studies found that group therapy was ideal in educating youths and adults about their symptoms and in providing ageappropriate explanations for the post traumatic course. In studies of Southeast Asian refugees who had suffered the death of a parent, children in group psychotherapy had better outcomes than the control group (Kinzie et al, 1988; Yule et al, 1990).

Another advantage of groups for traumatized children is their costeffectiveness over individual treatment. However, this requires evaluation to also include costing of the whole range of resources used by children and their families.

There may also be disadvantages in group work. Not all children feel comfortable sharing in a group, and some need more intensive individual

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treatment. Group discussion has the potential to re-traumatize children through re-exposure to their own experiences or those of others (children may prematurely adopt other young peoples coping strategies before fully examining their own responses). It is important to set limits on the expression of anger and aggression, which may create anxiety in peers and which may require individual work (Gillis, 1993). Chemtob, Nakashima and Carlson (2002) found that three treatment sessions resulted in substantial reduction of PTSD, anxiety and depressive symptoms in children with prolonged psychopathology, following exposure to a hurricane in Hawaii one year earlier, compared with waiting list controls. There has been even more limited evidence on the application of such programs in children who experienced war trauma.

Thabet & Vostanis (2005) 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 allocated to group intervention (N=47) encouraging expression of experiences and emotions through story telling, drawing, free play and role-play; education about symptoms (N=22); or no intervention (N=42). Children completed the CPTSDRI the CDI pre- and post-intervention. No significant impact of the group intervention was established on childrens 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.

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Field et al (1996) evaluated the impact of massage therapy or a video attentioncontrol condition in children exposed to Hurricane Andrew. The massage therapy group experienced significantly more improvement in PTSD symptoms than the control group. This study thus supported the use of muscle relaxation techniques in children with PTSD, however, such interventions usually target small numbers of children and may not be cost-effective. They may also be less acceptable to parents in this society.

Deblinger et al (1996) used trauma-focused cognitive behaviour therapy to treat sexually abused children by one of four treatment conditions: child-only receiving CBT, parent-only receiving CBT, child and parent receiving CBT, or assignment to a community treatment control. Results indicated that, although all groups improved in PTSD symptoms, the two conditions in which the child received direct treatment demonstrated significantly greater improvement in PTSD symptoms than the other two interventions.

Goenjian and colleagues (1997) found that, youths who received brief trauma/grief-focused psychotherapy after an earthquake in Armenia, had significantly fewer PTSD symptoms in all three symptoms clusters, while the severity of these symptoms increased significantly among the subjects not treated. In an intervention study of sexually abused children, the experimental

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group exhibited significantly greater improvement after one year than children treated with non-directive supportive therapy (Cohen & Mannarino, 1997). These studies showed the efficacy of brief focused individual psychotherapy, which could also be beneficial for selected children with PTSD.

Cognitive-behavioural interventions, mainly in group settings, have been associated with decrease in PTSD symptoms among children who experienced single incident stressors (March et al, 1998). King et al. (2000) studied 36 sexually abused children aged 517 years who met criteria for PTSD. There were 12 children in each of 3 conditions: CBT with child and family; CBT with child alone; waiting list control. Treatment conditions consisted of 20 sessions. Using ADIS-C to assess PTSD, there was a significant improvement on PTSD (p < .05) as well as on self reported anxiety scales. Both ways of delivering CBT were equally effective compared to the control group.

Cohen et al. (2004) showed that Trauma Focus-Cognitive Behaviour Therapy reduced PTSD, depression and total number of behavioural problems compared to a child-centred treatment for sexually abused children. The Trauma FocusCognitive Behaviour Therapy included training in expressive techniques, understanding of the relation between thoughts, feelings and behaviour, gradual exposure, cognitive processing of the event, joint sessions between parents and children, psychoeducation about sexual abuse or training of parents in parent management skills. The child centred treatment emphasised building a

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strengthening trusting relationship before children and parents themselves chose how and if they wish to approach the sexual abuse. The therapist was actively listening, reflecting, showed empathy and supported them in talking about feelings and showed confidence in the childrens and adults coping strategies. Although the work was client centred, written psychoeducative information about sexual abuse was provided and during two sessions the children were prompted to share their feelings about the sexual abuse

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References
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