The development and validation of the Palestinian children’s traumatic events checklist in a war-torn environment | BMC Psychiatry

Children have been the unseen victims of armed conflicts throughout history. Today, wars and hostilities spread to many places worldwide [1]. According to UNICEF [2], war negatively impacts children’s mental health, affecting their adjustment, self-concept, resilience, and quality of life.

The Israeli–Palestinian conflict could be regarded as continuing rather than a single, highly disrupting incident. Many of the violent war-like events children face in Palestine extend indefinitely. In this context, many generations of children have grown up knowing nothing except violent war-like events, conflicts, and traumatizing conditions [3].

The effects of war and violence on the mental health of children and adults are well known. They are often expressed through severe and chronic reactive psychological syndromes, including post-traumatic stress disorder (PTSD), anxiety, and behavioral problems [4]. The potentially traumatizing circumstances that can affect children when exposed to war-torn environments are less known. The Palestinian population living in the occupied territories has been subjected to continuous violence, such as shooting, bombardment, and physical injuries. As a result of this ongoing crisis, Palestinians, especially children, have developed severe psychological traumas [2].

Several studies reported that Palestinian children suffer from traumatic symptoms due to ongoing political conflict between the Israeli army and Palestinians. A survey conducted by Espié et al. [5] found that among 1254 Palestinian children living in Gaza Strip, 23.2% reported post-traumatic stress disorder (PTSD), 17.3% anxiety disorder (other than PTSD or acute stress disorder), and 15.3% depression. PTSD was more frequently identified in children ≤ 15 years old. Accordingly, among children ≤ 15 years old, episodes significantly associated with PTSD included witnessing a murder or physical abuse, receiving threats, and property destruction or loss. According to the meta-analysis study completed by Agbaria et al. [6], 28 articles, representing 32 samples with 15,121 participants from Gaza Strip and West Bank, were included in the study to measure the prevalence of post-traumatic stress disorder among Palestinian children and adolescents exposed to political violence. The survey showed the prevalence of PTSD was 36% (95% CI 30–41%; Sub-group analysis showed that the PTSD prevalence did not differ according to the West Bank and Gaza Strip regions.

Understanding how children experience such traumatic events as war, violence, and abuse requires measures and procedures to detect these potentially traumatic events (PTEs) children experience in their daily lives [7]. Since 1987, when the diagnosis of PTSD was extended to children and adolescents, efforts to study children’s exposure and reactions to possible stressors have used various methods. Further, we acknowledge that not always adverse and extreme experiences will necessarily lead to trauma symptoms and syndromes. As a result, it is difficult to characterize the prevalence of PTEs or to accurately assess them among children without using standardized and validated instruments [8].

From a relativist’s perspective, where the notion holds that all human behaviors are culturally patterned, the cross-cultural validity of trauma experience has been questioned for many years. The categorization of trauma experiences is based on agreed-upon notions of how a person is supposed to interpret adversities. These notions, and therefore experiences of trauma, are shaped by culturally informed protective strategies, environmental constraints, and context-specific forms of violence. These context-driven influences on the experiences of trauma pose several challenges in addressing traumatic events, understanding and assessing differing sociocultural contexts, therefore developing sensitive cultural methods to classify PTEs [9, 10].

Several studies have been implemented to validate trauma screening checklists in international contexts. Viola et al. [11] tested the validity of the Childhood Trauma Questionnaire in a multicounty study (CTQ). The CTQ is a self-administered questionnaire that persons aged 12 years and older can fill out. Five elements–including emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect–were used to evaluate each subtype of childhood maltreatment. Europe and Asia had the lowest CTQ figures compared to South America, with the highest estimates. Specifically, studies from China, the Netherlands and the United Kingdom yielded the most conservative maltreatment estimates.

Choi et al. [12] developed and validated the Traumatic Events Screening Inventory (TESI) for vulnerable children in Chicago. The TESI advances beyond preceding instrumentation by encompassing both a child’s and parent’s version of the tool to assess a wide range of adverse childhood experiences. The questionnaire was given to a group of consecutively seen intakes from child psychiatric outpatient clinics. Identifying if the child has experienced a traumatic event provides the clinician with a broader insight into their functioning, aiding in treatment. The TESI has potential applications in clinical research and can be combined with other methods. More recent results showed strong validity and reliability indicators of TESI in assessing traumatic experiences among vulnerable children.

The Stressful Life Events Schedule for children and adolescents [13] encompasses over 300 PTEs clustered in severe and non-severe events. The Life Events and Difficulties Schedule (LEDS), which is an investigator-based semi-structured interview to measure stressful life events in children [14], represent a significant step forward in evaluating environmental stressors. Still, their use is limited because of the labor and time they involve. For example, specific tools for detecting PTEs have been developed by the UK police for children and their parents [15].

Hence, it is imperative for professionals dealing with kids and families who are war-torn and displaced to be sensible of and evaluate the numerous traumatic experiences kids have been confronted with [16].

In Palestine, over the years, numerous tools aimed at recording PTEs related to war and violence have been developed [4, 17]. For example, typical PTEs occurred among children during the first intifada were summarized in 10 items that were expanded in updated versions of the first tool.

The most advanced instrument detecting traumatic events related to war was construed by Thabet and Vostanis [18]. The original version of the Gaza Traumatic Checklist – Parent Form was constructed by the research branch of the Gaza Community Mental Health Programme and incorporated 17 items that canvassed various kinds of traumatic situations that the child may have encountered [19]. Considering the transformation of the political dispute in the territory, this checklist was adjusted to include new items, such as witnessing the bombardment of homes by helicopters, heavy artillery and tanks and witnessing mutilated bodies on television. Fathers and mothers were canvassed regarding the episodes their offspring had undergone in the past 12 months. The checklist scores were evaluated by summing the scores and scores stratification (low traumatic exposure for scores under 5, moderate exposure for scores between 5–9, and high exposure for scores of 10 and more). The authors also evaluated the impact of specified traumatic events, i.e. the presence or absence of each event, i.e. the presence or absence of each checklist item. More recently, El-Khodary et al. [20] readapted the War-Traumatic Events Checklist (W-TECh) with Gaza children. The authors were the ones to construct the W-TECh. Some items were derived from Thabet et al. [21] prior study. The items were adapted to suit the most recent armed conflict consequences in the Gaza Strip. The W-TECh is formed of 28 binary answers separated into three clusters. The first comprised experiencing personal trauma when kids and teenagers are exposed to direct war-related trauma, such as being struck or harmed by bullets. Witnessing traumatic events with children or adolescents as observers (e.g., family members, friends, or neighbors) being shot and/or injured during the war. Finally, a third dimension is seeing the demolition of a property when victims witnessed demolishing their home, school, and/or farm during the war. None of these instruments in Palestine was validated and tested for their psychometric properties.

Hence, the existing trauma instruments are still limited in detecting clusters of war-related trauma events. There is a need for a user-friendly and psychometrically robust tool to assess traumatic events among Palestinian children living amidst chaotic and catastrophic conditions that would help to explain how children might develop specific traumatic symptoms and diagnoses of trauma. The current study aims to develop and validate a new trauma checklist and test its psychometric properties and factorial structure as an easy-to-use and robust assessment instrument for Palestine children affected by war and political violence.