who are the resilient children in conditions of military violence?

Who Are the Resilient Children inConditions of Military Violence?

Family- and Child-Related Factorsin a Palestinian Community Sample

Raija-Leena PunamakiDepartment of Psychology, School of Sciences and Humanities

University of Tampere, FinlandHelsinki Collegium for Advanced Studies University of Helsinki, Finland

Samir QoutaDepartment of Psychology

Islamic University of Gaza, Palestine

Thomas MillerHand and Upper Limb Centre, St. Joseph’s Health Care

Queen’s University, Kingston, Canada

Eyad El-SarrajGaza Community Mental Health Program, Palestine

The prevalence of resilience in the presence of military violence and the role ofchild and family characteristics fostering that resilience were analyzed in aPalestinian community sample using a person-based approach. The parti-cipants consisted of a random sample of 640 Palestinian children and adoles-cents, their parents, and their teachers, all living on the Gaza Strip. A medicalexamination of the children and adolescents was conducted to assess health

Richard V. Wagner served as action editor for this article.

Correspondence should be addressed to Raija-Leena Punamaki, Department of Psychology,

Helsinki Collegium for Advanced Studies, University of Helsinki, P.O. Box 4 (Fabianinkatu

24), FIN-0014, Finland. E-mail: [email protected]

Peace and Conflict, 17: 389–416, 2011

Copyright # Taylor & Francis Group, LLC

ISSN: 1078-1919 print=1532-7949 online

DOI: 10.1080/10781919.2011.610722

389

status on somatic, sensory, and cognitive domains. The results revealed anequal share of resilient (21%; high level of trauma and low level of disorders)and traumatized (23%; high level of trauma and high level of disorders) chil-dren. As hypothesized, characteristics of the resilient group were good parentalmental health, supportive parenting practices, good school performance,superior cognitive functioning, good physical health, high body weight, andnormal birth weight. Variable-based analyses revealed no support for thehypothesis that these family- and child-related factors protect child mentalhealth, although their direct association was confirmed. The discussion focuseson mechanisms fostering child resilience in war zones.

Attempts to win wars are not accomplished by using superior high-techweaponry, military arms, and personnel alone. The social and psychologicaldestruction of targeted communities are increasingly prevalent in modernwarfare. Children and their families are becoming direct targets in armedconflicts, and what was usually regretted as ‘‘collateral damage’’ has, insome cases, become accepted war doctrine. For instance, the Dahiadoctrine, endorsed by the Israeli Defense Force, uses indiscriminate and dis-proportionate power to cause immense damage and destruction to theadversary’s residential areas (United Nations [UN], 2009). Therefore, indi-vidual and community resiliency in the face of war trauma becomes para-mount for survival. Resilient children are those who, despite exposure tosevere adverse and traumatic experiences, do not suffer from significantmental health problems. Some of these children may even show high devel-opmental competence and even become emotionally stronger following thetrauma (Luthar, Cicchetti, & Becker, 2000; Masten & Coatsworth, 1998;Rutter, 2000). Heroism and self-sacrifice are highly valued in war, and anec-dotes about ‘‘war children’s’’ impressive endurance are common. However,there is scant empirical evidence about the prevalence of and factorscontributing to resilience in a war context. This study focuses on the pre-valence of resilience and on family- and child-related factors that fosterresilience among Palestinians living in the midst of armed conflict.

NATURE OF RESILIENCE

Resilience as a dynamic link between adverse conditions and psychosocialadjustment has been conceptualized either as a category—individuals who,despite exposure to severe adversity, show relatively high competence—oras a buffering factor that protects child health and developmentalcompetence from the negative impact of trauma (Shaffer, Burt, Obradovic,

390 PUNAMAKI, QOUTA, MILLER, AND EL-SARRAJ

Herbers, & Masten, 2009). We could not find studies applying a categoricalapproach to child resilience in armed conflict, although increasing researchis available on protective processes. One study identified resilience trajec-tories among adult survivors of terrorist attacks in Israel (Hobfoll et al.,2009), documenting the resilience rate to be 13%. Other studies have con-ceptualized war-related resilience as a lack of expected posttraumaticstress disorder (PTSD). For example, one study documented that 63% ofsurvivors of a terrorist attack were resilient as measured by the absence ofpsychiatric disorders (Bonnano, 2004). Similarly, resilience among childrenin armed conflicts is commonly described as those children who showcompetence and a lack of mental health problems (Stichick Betancourt &Khan, 2008).

Several researchers have attempted to apply multiple criteria of resilience,including social, academic, and mental health domains, depending on theadaptation skills related to the particular traumatic stress (Luthar &Cushing, 1999; Masten, 2007). Children living in armed conflict situationshave the dual challenge of securing both their physical and emotional sur-vival while trying to accomplish normative development. The evidence isclear that accumulation of severe war trauma increases the likelihood ofchildren’s mental health problems, including PTSD, depression, anxiety,excessive fear, and aggression (Barenbaum, Ruchkin, & Schwab-Stone,2004; Vostanis, 2004; Yule, 2000). Consequently, it is legitimate to defineresilient children in armed conflict as those who are exposed to severe loss,atrocity, and destruction, and yet lack psychiatric disorders. In other typesof traumatic situations, different criteria for resilience may be emphasized.For instance, social competence and emotion regulation capacities are con-sidered salient in family violence because these children may more easily findcompensatory social experiences and extra-familial safety (Zucker, Wong,Puttler, & Fitzgerald, 2003). Resilience in the academic domain may besignificant for children living in poor, violent, and deprived communitiesbecause successful school performance can lead to new, positive opportu-nities for those children (Fergusson & Horwood, 2003; Garmezy, 1990).

In our study of children on the Gaza Strip, we applied a classification ofresilience suggested by Werner and Smith (1982), depicting the balancebetween the severity of trauma and emergence of mental health problems.A 2� 2 grid was created to categorize children according to the severity oftheir personal exposure to military trauma (high or low) and the presenceor absence of emotional and conduct disorders. This resulted in four groupsof children: resilient (high trauma exposure and absence of disorders), trau-matized (both high exposure and presence of disorders), vulnerable (lowtrauma exposure, but presence of disorders), and spared (both low exposureand absence of disorders). The resilience classification is presented in Table 1

FACTORS FOSTERING RESILIENCE 391

RESILIENCE-FOSTERING FACTORS

Child resilience has been attributed to compensating social and individualfactors related to community, family, and the children themselves. Empiricalevidence elucidates explanatory factors for resilience among children livingin poverty (Fergusson & Horwood, 2003; Garmezy, 1990), family violenceand maltreatment (Bolger & Patterson, 2003; Cicchetti, Rogosch, Lynch,& Holt, 1993), and community violence (Luthar, Doernberger, & Ziegler,1993; O’Donnell, Schwab-Stone, & Muyeed, 2002). Child resilience is poss-ible in communities that appreciate human rights and provide equal oppor-tunities for education. Resilient children go to schools that typically have arespectful and stimulating learning atmosphere, with families characterizedby high cohesion, secure bonding, and authoritative and supportiveparenting styles (Masten & Coatsworth, 1998; Olsson, Bond, Burns, Vella-Brodrick, & Sawyer, 2003). Resilient children themselves are able to processstressful and traumatic experiences by seeking realistic causal explanationswithout being overwhelmed by guilt and fear (Beardslee & Podorefsky,1988). Also, they show curiosity, prosocial attitudes, and a willingness tocreate novel, flexible solutions to problems (Masten et al., 1988; Zuckeret al., 2003).

Despite observations of resilience among children living in armed con-flicts, relatively few studies have empirically examined factors that mayexplain their unique resilience. Evidence is available on family and individ-ual characteristics fostering resilience, based on analyses of protective fac-tors moderating between severe trauma and mental health problems suchas PTSD and depression (Bonnano, 2004). Stichick Betancourt and Khan(2008) identified multiple ecological layers of protective processes in the livesof war-affected children in acute and post-war settings. Social and

TABLE 1

Conceptualization of Resiliency as a 2� 2 Classification of Trauma

and Psychiatric Disorders

Emotional and conduct disorders

Absence of disorders

(none of the 3)

Presence of disorders

(1 to 3)

Exposure to traumatic

events

Low exposure

(2–5 events)

Spared children Vulnerable children

High exposure

(6–18 events)

Resilient children Traumatized children


family-related factors fostering resilience include secure attachment relation-ships, appropriate peer support, and good caregiver mental health. Empiri-cally, loving and accepting parenting has been found to buffer Palestinianchildren from depressive (Barber, 2001) and aggressive (Qouta, Punamaki,Miller, & El-Sarraj, 2008) symptoms in life-endangering conditions of mili-tary occupation. Loving and supportive parenting was further associatedwith children’s creativity and cognitive capacity, which, in turn, contributedto good psychological adjustment, despite severe trauma exposure(Punamaki, Qouta, & El-Sarraj, 2001), suggesting that motivational andcognitive-emotional functioning might be the mechanisms through whichgood parenting fosters resilience. One study confirmed that social supportand optimal caregiver relationships promoted resilience among refugeechildren fleeing armed conflict (Hodes, Jagdev, Chandra, & Cunniff,2008). Intact maternal mental health has been documented as one of themain ‘‘secrets of resilience’’ in many wars, including in former Yugoslavia(Smith, Perrin, Yule, Hacam, & Stuvland, 2002) and the Middle East(Qouta, Punamaki, & El-Sarraj, 2005). Finally, a sensitive mother–childrelationship that enhances secure attachment can protect the offspringacross their lifespan (Kanninen, Salo, & Punamaki, 2000; Mikulincer,Horesh, Eilati, & Kotler, 1999).

Individual characteristics and protective factors that may predict childresilience in armed conflicts are pre-trauma strengths and resources such asconstitutional health and temperamental characteristics of curiosity andbalanced emotionality, flexible and creative cognitive-emotional processingof trauma, and active and constructive coping strategies (Bonnano, 2004;Bonnano, Rennicke, & Dekel, 2005; Yule, 2000). Good cognitive capacity,involving high intelligence and self-efficacy, is considered to promoteresilience both in general (Cicchetti et al., 1993; Luthar et al., 2000) and inarmed conflicts and wars. A Lebanese study showed that children with soph-isticated problem-solving skills, high self-efficacy, and high intelligence wereat lower risk of PTSD, despite high exposure to war violence (Saigh, Yasik,Oberfield, Halamandaris, & Bremner, 2006). Flexible cognitive style involv-ing accurate attention, learning, and making sense of experiences protectedPalestinian children’s mental health from negative trauma impacts (Qouta,Punamaki, & El-Sarraj, 2001), and predicted low PTSD and depression inadolescence (Punamaki, Qouta, Montgomery, & El-Sarraj, 2007).

The classic studies on resilience focused on children with early neurobio-logical risks living in social-economic adversity (Garmezy, 1990; Werner,1993) and in families where parents had mental disorders (Anthony, 1974;Hammen, 2003). Contemporary developmental research emphasizes the roleof early optimal caregiving relations in fostering resilient development,despite adverse conditions, as they provide compensatory effects on


neurobiological deficiencies (Bradley et al., 1994; Curtis & Nelson, 2003).Pregnancy- and birth-related risks predict long-term developmental andhealth problems in children, especially when they face stress and adversity(Allen, Lewinsohn, & Seeley, 1998; Stelmach, Kallas, Pisarev, & Talvik,2004; Strathearn, Gray, O’Callaghan, & Wood, 2001). There is evidenceof impacts of famine during pregnancy on children’s future vulnerabilityto obstetric problems and various somatic illnesses (Susser, Brown, &Matte, 1999), and traumatic exposure to the 9=11 terrorist attacks has beenfound to have negative impacts on pregnancy outcomes (Mulherin Engel,Berkowitz, Wolff, & Yehuda, 2005; Yehuda & McEwen, 2004). Resilienceresearch in armed conflict has, however, ignored good somatic health andoptimal constitutional and neuropsychological functioning as possiblecontributors to resilient child development.

STUDY OF RESILIENT CHILDREN

Aims of the Study

The aims of this study are to examine the prevalence of resilience amongchildren who live under conditions of war and military violence, and to ana-lyze which family- and child-related factors foster the resilience. The resili-ence is defined in Table 1. First, we hypothesize that the resilient children(high trauma exposure and absence of disorders), compared to the trauma-tized and vulnerable children, have higher socioeconomic status and higherparental education, and the parents have better mental health and use moresupportive and non-punitive parenting practices. The resilient group isexpected not to differ from the spared children (low exposure and absenceof disorders) in these family characteristics. Second, compared to the trau-matized group, we hypothesize that the resilient group of children do betterat school and, third, have better early and current health status (i.e., lessante- and perinatal complications such as low birth weight and current highbody weight and good health). Fourth, we hypothesize that the resilientgroup demonstrates more optimal cognitive-emotional functioning (e.g.,memory, problem solving, and regulation capacities) than traumatized chil-dren. The resilient children are expected not to differ from the spared groupin these individual characteristics.

Furthermore, we examine whether the role of resilience-fostering family-and child-related factors differs in regard to (a) gender, (b) developmentalstages (middle childhood, early adolescence, and adolescence), (c) age, (d)place of residence, and (e) family size.


METHOD

Participants

This study utilized the dataset collected on 640 children from the Gaza ChildHealth Survey (GCHS) conducted in Gaza in 1996 (Miller, El-Masri, &Qouta, 2000). Of the participants, 54.7% were girls and 45.3% were boys.The participants ranged from 6 to 16 years of age. The majority of parti-cipants (64.5%) were in middle childhood (6–11 years), 12.6% were in earlyadolescence (12–13 years), and 20.9% were adolescents (14–16 years). Therewere no gender differences in age groups: v2(2, N¼ 640)¼ 3.44, p¼ ns.Information about children’s mental health, family issues, and traumaticexperience was collected using in-depth questionnaires completed by theyouth group (age 12 and up) themselves and by the children’s and youths’parents and teachers. Also, a physical health examination was conductedon 622 children.

The original survey sample size in the GCHS was 704 children and ado-lescents and 669 parents. The non-completion rate was, thus, 5%, as 35 fam-ilies were not reached or parents refused to participate. Only 622 childrencompleted the physical examination because of the practical difficulty ofreaching them during the occupation.

The random sample reflects the social status distribution on the GazaStrip during the Palestinian Authority rule after the Oslo Agreement. Withrespect to parent education, no formal education was reported in 13.8% ofmothers and 8.6% of fathers, and 20.3% of mothers and 25.2% of fathershad an elementary education (Grades 1–6). About one-fourth of bothmothers (24.7%) and fathers (22.6%) had completed preparatory school(Grades 7–9), and about one-third of mothers (38.6%) and fathers (32.1%)had completed secondary education with a diploma. Finally, university edu-cation was more common among fathers (12.5%) than mothers (2.6%). Themean number of people living in each household was 9.70 (�2.95), and themean number of children per household under the age of 16 was 6.0 (�2.4).Almost one-half (46.3%) lived in urban areas, one-fourth (24.6%) in refugeecamps, one-fifth (20.6%) in villages, and 8.5% in resettled areas that areextensions of refugee camps.

The father was reported to be the main income earner in the majority(89.9%) of the families. The brother and the mother comprised the remain-ing main income earners in 4.3% and 2.7% of the families, respectively.Household income levels were determined by asking the respondent toindicate the job category of the main income earner and the number ofmonths that person had worked full time in the past 1 year. This incomelevel distribution in the sample was divided into upper (professionals,


19.6%), middle (skilled laborers 30.8%), and lower (unskilled laborers,49.6%) social classes. Estimates of income level were utilized instead ofdirect inquiry, which was not considered proper.

Study Design

A two-stage random sampling design was applied. In the first stage, a list ofall schools on the Gaza Strip was created. From that list, schools were strati-fied based on geographic location (town, refugee camp, village, or resettledarea). Second, a list was prepared that included all of the pupils in thoseschools. That list was stratified according to gender and age, and the allo-cated number of students from each geographic location was randomlyselected from that school list. The address of the student was obtained fromthe school, and the interviewers then met the parent or main caregiver of thestudent to obtain consent to participate in the survey. At that time, an intro-ductory letter was presented to the parents or main caregiver describing thepurpose of the survey and requirements of the research. Consent wasobtained by verbal approval from the parents or main caregiver for the childparticipating in interviews and physical health examinations.

Eight fieldworkers administrated the questionnaires to children and par-ents at their homes and to the principal teacher of the child at the school.Seven of the eight fieldworkers were women. The mother was the informantin the majority of cases (76.0%). The father reported in 16.1% of cases; andin 7.9% of cases, the informer was another family member (aunt, uncle, etc.).A female pediatrician and a female nurse conducted the physical healthexamination in the school buildings. An authorization letter obtained fromthe Palestinian Authority Minister of Education facilitated the researchers’access to the schools.

Translation of the questionnaire was conducted by members of thePalestinian research team, who are all fluent in English and Arabic. Thequestionnaire was translated from English to Arabic, and then indepen-dently back-translated to English. Comparison of wordings and conceptswere discussed among the research team, and any differences were resolvedby consensus. Special attention was paid to ensure that key phrases wereexpressed in colloquial Arabic specific to Gaza. The questionnaire was pilottested in 30 randomly selected households, and the results were used to mod-ify questions, words, and concepts that turned out to be difficult to compre-hend and answer. Furthermore, test–retest reliabilities were conducted onthe main instruments in the survey in 25 households. The questionnaireswere administered 1 week apart. The intraclass correlation of each of theinstruments ranged between 0.77 (Parent Form for Emotional Disorder)and 0.89 (Teacher Form for Emotional Disorder).


Measures

Demographics. Demographic factors included the father’s and mother’seducation (no education, preparatory and primary school, secondary edu-cation, and university), family income status (high, middle, or low), placeof residency (refugee camp, town, village, and resettled area), and familysize.

Traumatic events. The exposure to military violence was assessed by an18-event list modified from the War Trauma Questionnaire by Macksoudand Aber (1996). It covers events of direct physical violence targeted atthe child (e.g., beaten, chased by soldiers, and bullet wounds) or indirector witnessed events to a close person (e.g., witnessing killing or woundingof a family member or friend), psychological violence (e.g., verbal threatsor preventing access to health services), material losses (e.g., home demo-lition), and arrest and detention of the child or family members. The parentsand the child were asked whether the child had been exposed to each ofthese events during the First Intifada (0¼ no and 1¼ yes). If the answerwas yes, then they were also asked to estimate how many times thatexposure had occurred during the child’s or adolescent’s lifetime. A sumvariable was constructed by accounting for the occurrences of the traumaticevents, ranging between 2 and 18 in this sample. Unfortunately, there wereno children with zero exposure, and constructing a dichotomous variable fora 2� 2 grid for resilience classification is problematic. The traumatic eventsvariable was dichotomized to indicate low (2–5 events) and high (6–18)levels of traumatic events, using the median split as a cutting point. Themean score was 5.6 (�2.38) in the sample. The decision of the cutoff pointis based on both empirical statistics and contextual analyses of the phenom-enon (Luthar & Cushing, 1999). Earlier research among Palestinian childrenhas shown a threshold, rather than a dose-effect, of trauma impact onmental health problems, the critical accumulation being five to six events(Garbarino & Kostelny, 1996).

Emotional and conduct disorders. These were measured using theOntario Child Health Scale, which was applied as an interviewer-administered checklist for parents and teachers (Boyle & Pickles, 1997).The scale uses Diagnostic and Statistical Manual of Mental Disorders (3rded.; American Psychiatric Association, 1980) criteria, and consists of 34questions that measure three mental health disorders: conduct disorder,emotional disorder, and attention deficit hyperactivity disorder. The parentsand teachers were asked to rate how well the items describe the child’s


behavior on a 3-point Likert scale now or within the past 6 months; the scaleranged from 0 (never true), 1 (sometimes or somewhat true), to 2 (often orvery true). The cutoff value for the resilience classification was absence orpresence of disorders, and a dichotomized variable was accounted for:values were 0¼ absence of disorder indicating no conduct, emotional, andhyperactivity disorders (55.5% of children) and 1¼ presence of disorderindicating any of the three disorders. One-third (30.6%) had one disorder,9.2% had two disorders, and 4.8% had all three disorders. In addition, threesum variables were constructed to indicate emotional, conduct, and totaldisorders by combining parents’ and teachers’ linear scores.

Resilience classification. This was constructed according to Wernerand Smith (1982) and Fergusson and Horwood (2003), referring to childrenwho had been exposed to severe trauma, but show absence of psychopath-ology. The cross-tabulation of the dichotomized variables of traumaticevents and psychiatric disorders resulted in four groups (see Table 1): sparedchildren (low exposure to traumatic events and absence of psychiatric dis-order), vulnerable children (low exposure to traumatic events and presenceof psychiatric disorder), resilient children (high exposure to traumatic eventsand absence of psychiatric disorder), and traumatized children (highexposure to traumatic events and presence of psychiatric disorder).

Parental mental health. This was assessed using five questions concern-ing the mother’s and father’s mental health during the past year. The par-ents responded, for both themselves and their spouses, regarding whetherthey had the following experiences in the past year (yes¼ 1 and no¼ 0):seeking help for nervous or emotional problems, being often sad ordepressed, feeling incapable to cope with stress, receiving medication foremotional problems, and hospitalization for psychological problems. Separ-ate sum variables were formed for mothers and fathers, ranging betweenzero and five.

Parenting practices. These were assessed by a nine-item scale (Barber,2001) indicating parents’ approaches to discipline in a situation where thechild has broken a rule. The parenting dimensions included punitive prac-tices (e.g., from making threats to punishment), controlling practices (e.g.,telling the child how to behave), and guidance and negotiation (e.g., calmlydiscussing the problem). Parents evaluated their own behavior toward thechild, and youth separately reported their mother’s and father’s behaviortoward them on a 3-point Likert scale ranging from 1 (never or rarely), 2(sometimes), to 3 (often or always). A sum variable indicating the qualityof parenting practices was constructed, which had moderate reliability


(Cronbach’s a¼ .64 for parents’ reports and a¼ .69 for children’s reports).The low score indicates a negative (punitive) disciplining style, and the highscore indicates a positive (negotiating) style; negative items were reversecoded. For this analysis, parents’ and children’s scores were combined(r¼ .33, p< .0001).

School performance. This was assessed using three questions for tea-chers: the target child’s overall grade directly scored from school assessment(scores of 1–5), grade repetition (1¼ no, and 2¼ yes), and the number oftimes of repeating the class.

Physical health and cognitive-emotional functioning. A female pedia-trician and a female nurse conducted a standard medical examination ofchildren’s health status and functioning. The Health Utilities Index Mark2 (Feeny, Furlong, Boyle, & Torrance, 1995) is a standardized questionnairethat evaluates child health on six domains: sensation, mobility, cognition,emotional-behavioral, pains and complaints, and general physical health.Each domain is estimated on a 4-point scale ranging from 1 (absence of ahealth problem) to 4 (presence of a severe problem). The instrument has fre-quently been used as a global measurement of children’s physical health,and has been found valid to screen children with severe somatic illnessesand risks (Feeny et al., 1995). We formed two averaged sum variables basedon exploratory factors: physical health (pains and complaints and generalphysical health) and cognitive-emotional functioning (cognitive andemotional-behavioral). Information on sensation and mobility was omitteddue to little variation and non-importance for the hypotheses. A measure ofthe body mass index—the relation between child length and weight—wasdetermined by the pediatric team.

Ante- and perinatal problems. These were assessed by questions to theparent: occurrence of pregnancy complications (yes or no) and their nature(e.g., blood pressure, sugar, or bleeding), gestation term, normal delivery(yes or no), birth weight (in kilograms; low is <2.500, and normal is>2.500), and health problems of the newborn (yes or no) and the natureof these problems (e.g., infection, breathing problems, or unconsciousness).

Statistics Analyses

The associations between demographic factors and the ante- and perinatalinformation and resilience category (resilient, traumatized, vulnerable, andspared children) were analyzed by cross-tables with Pearson’s chi-squarestatistics. To analyze the family- and child-related factors in association with


the type of resilience, one-way analyses of covariance (ANCOVAs) withSheffe’s post hoc tests were conducted. The hypothesized predisposing vari-ables were parental mental health, parenting practices, child school perfor-mance, physical health, and cognitive-emotional functioning; and thebetween-subject variable was the resilience classification. The associationsbetween child age and family size and resilience classification was similarlyanalyzed by using ANCOVAs.

The linear total score of traumatic events served as a covariant becausethere was a possibility that the resilient group would have a lower level oftraumatic events than traumatized children, although both belong to thesame category of high exposure. Pretesting showed, indeed, that the trauma-tized group (6.64� 15.00) had a higher average level of traumatic eventsthan the resilient group (5.86� 15.00), Sheffe’s test¼ 3.73, p< .004. No dif-ferences were found between spared and vulnerable groups in the level oftraumatic events. In case the covariant turned out to be significant, weretested the hypothesized differences between resilient, traumatized, andspared groups by applying difference method contrasts to ensure the sus-tainability of the hypothesized associations between the resilience classi-fication and family- and child-related factors.

The hypotheses for the family- and child-related factors fostering chil-dren’s resilience were substantiated when there were significant differences(Sheffe’s post hoc tests, p< .01) between the resilient and traumatizedgroups, and no differences (nonsignificant post hoc values) between theresilience and spared children’s groups. This logic is based on the definitionof the groups: Both resilient and traumatized groups have been exposed to ahigh level of traumatic events, but only the latter suffers from emotional andconduct disorders. Similar to spared children, resilient children lack disor-ders, despite their high levels of exposure to trauma.

To analyze the role of gender and developmental stage in resilience-fostering factors, further 4 (Resilience Classification)� 2 (Gender)� 3(Age: 6–11, 12–13, and 14–16) ANCOVAs on family factors (parentalmental health and parenting practices) and child characteristics (schoolperformance, physical health, and cognitive-emotional functioning) wereperformed.

RESULTS

Descriptive Statistics

Table 2 presents the means and standard deviations of traumatic events,family factors and child’s health, cognitive-emotional functioning, and


psychiatric disorders among girls and boys. No gender differences werefound in the exposure to traumatic events, school performance, or physicalhealth. Girls’ mothers and fathers reported, however, higher levels of mentalhealth problems than boys’ parents, and parenting practices were moresupportive of girls and more punitive for boys. Boys had poorercognitive-emotional functioning than girls.

The Prevalence of Resilient Children

The results reveal a rather identical distribution of the resilience categories:21% of children were classified as resilient, 23% as traumatized, 23% as vul-nerable, and 33% as spared from both trauma and psychological disorders.Table 3 shows gender differences in the resilient and spared groups, but not

TABLE 2

Means and Standard Deviations of Traumatic Events, Family and Child

Characteristics, Child Psychiatric Disorder, and t Test Values

According to Gender

Girls Boys

Variable M SD M SD t

Traumatic events

Numbers of physical direct trauma 8.07 6.93 9.27 9.76 �1.78

Numbers of witnessing indirect trauma 6.89 7.51 5.87 6.21 1.56

Family factors

Mother’s mental health 0.96 1.38 0.64 1.21 3.09��

Father’s mental health 1.01 1.53 0.70 1.38 2.68��

Parenting practices 19.19 2.65 18.58 2.50 2.87��

Size of family (extended) 9.83 2.95 9.58 2.99 1.07

Number of siblings 5.83 2.40 6.26 2.44 2.22�

Child characteristics

Age 10.40 2.93 10.64 3.09 1.02

Overall school grade 2.92 1.29 2.75 1.30 1.56

Number of repeating class 1.42 1.18 1.33 0.70 0.41

Body mass index 17.05 4.25 16.52 2.85 1.77

Physical health 1.36 0.60 1.40 0.66 0.79

Cognitive-emotional functioning 1.70 0.53 1.97 0.59 5.87��

Psychiatric disorders

Emotional disorder (parent reports) 7.35 3.32 7.29 3.79 0.23

Conduct disorder (parent reports) 2.09 2.84 3.52 3.84 �5.29��

Note. Sample sizes differ due to missing values.�p< .05. ��p< .01. ��p< .001.


in the traumatized group. In this sample, 27% of boys and 19% of girls wereresilient, and 38% of the girls and 28% of the boys were spared. Childrenfrom villages were less resilient (10.5%) than children from refugee camps,towns, or resettled areas (23.0%–27.5%). Children from refugee campsbelonged more often to the traumatized group (33%) than other children(14%–22%), whereas children from villages and resettled areas were moreoften spared from both high trauma exposure and disorders.

TABLE 3

The Distribution and Percentages of Demographic Variables According to Resilience

Classification

Spared

children

Resilient

children

Vulnerable

children

Traumatized

children

Predictors % n % n % n % n v2

Gendera (3, N¼ 617)¼ 9.83�

Girls 38.1 128 19.0 64 19.0 64 23.5 79

Boys 28.1 79 23.5 66 26.7 75 21.7 61

Father education (9, N¼ 615)¼ 31.78��

No education 7.3 15 11.6 15 12.1 17 4.3 6

Obligatory schoolb 41.7 86 45.6 59 49.3 69 57.1 80

Secondary education 30.1 62 35.7 46 27.1 38 32.1 45

University 20.9 43 6.0 9 11.4 16 6.4 9

Mother education (9, N¼ 616)¼ 16.46

No education 14.5 30 16.2 21 12.9 18 11.4 16

Obligatory schoolb 44.9 93 42.3 55 47.5 66 45.0 63

Secondary education 34.8 72 40.0 52 38.1 55 43.6 61

University 5.8 12 1.5 2 1.4 2 0.0 0

Family income status (6, N¼ 562)¼ 8.01

High 25.4 49 16.8 20 15.5 20 17.1 21

Middle 25.9 50 33.6 40 31.5 40 35.0 43

Low 48.8 94 49.6 59 52.8 67 48.0 59

Place of residency (9, N¼ 601)¼ 40.87��

Refugee camp 26.4 39 25.7 38 14.9 22 33.1 49

Town 31.3 87 23.4 65 23.0 64 22.3 62

Village 43.5 54 10.5 13 32.3 40 13.7 17

Resettled area 43.1 22 27.5 14 13.7 7 15.7 8

aWe count the percentages across gender, not across the resilience categorizationgroups, as other demographic factors.

bObligatory schooling refers to the elementary and preparatory school up to 16years old. Secondary education may be gymnasium, vocational, or polytechnicschool.

�p< .05. ��p< .0001.


Resilience Fostering Factors

Family-related factors. Contrary to the hypothesis, the resilient chil-dren did not typically come from families with high socioeconomic or edu-cational status, as indicated by nonsignificant group differences in familyincome and mother’s education. In fact, as shown in Table 3, in the resilientgroup, fathers had significantly less education than in the other groups. Ofthe resilient children’s fathers, 12% were without formal education, and only6% had university education, whereas the corresponding percentages were7% and 21% among spared children, respectively. Also among traumatizedchildren, only 4% of fathers were without education, although the universityeducation was as rare as in the resilience group.

As hypothesized, both mothers and fathers of the resilient children hadlower levels of mental health problems than parents in the traumatizedgroups, whereas parental mental health did not differ between the resilientand spared children (see Table 4). Also as hypothesized, supportive parentingpractices were more common in the resilient than in the traumatized group,and there were no differences between the resilient and spared children. Thesize of extended family was not associated with child resilience; and, althoughthe number of siblings had a significant main ANCOVA effect (p> .05),Sheffe’s post hoc tests did not show significant group differences.

Traumatic events turned out to be a significant covariant for maternaland paternal mental health. Difference method contrasts confirmed the ear-lier result that maternal and paternal mental health was significantly betterin the resilient than in the traumatized group (p< .002 for mothers’ andp< .003 for fathers’ mental health) and similar or as good (p¼ ns) betweenthe resilient and spared children.

Child-related factors. As hypothesized, resilience was associated withgood school performance, good physical health, and optimal cognitive-emotional functioning (see Table 4). The overall school grades were higheramong both resilient and spared pupils than among traumatized ones, andtraumatized pupils had more often repeated classes than both resilientand spared children. Resilient children had better physical health andcognitive-emotional functioning than the traumatized group, and were ata similar level with the spared children. Resilient children had a higher bodymass index than all other children’s groups. Traumatic events were a signifi-cant covariant on body mass index; and similar to Sheffe’s post hoc tests,the difference method contrasts showed that resilient children had higherbody mass indexes than the traumatized group (p< .001); however, it alsowas higher compared to spared children (p< .01).


TABLE4

Means,

Standard

DeviationsandANCOVAStatisticsofFamily-andChild-R

elatedFosteringFactors

Accordingto

theResilienceClassification

Sparedchildren

Resilientchildren

Vulnerable

children

Traumatized

children

Predictors

MSD

MSD

MSD

MSD

Fg2

,a

Familyfactors

Mother’smentalhealthb

0.40 a

0.07

0.39a,b

0.09

0.75b

0.09

1.12 c

0.09

17.39�

��.08

Father’smentalhealth

0.46 a

0.09

0.61a

0.10

0.64a

0.11

1.20 b

0.10

10.55�

��.05

Parentingpractices

c21.34 a

0.21

21.28 a

0.25

19.99b

0.24

20.21b

0.24

9.09�

��.04

Familysize

(extended)

9.58

0.21

9.76

0.25

9.32

0.26

10.21

0.25

2.29

.01

Number

ofsiblings

5.80

0.17

5.68

0.21

6.38

0.20

6.39

0.20

3.63�

.02

Childcharacteristics

Age

10.17 a

0.20

11.82 c

0.25

9.56a,b

0.25

10.90b

0.24

15.92�

��.07

Schoolgraded

3.22 a

0.09

2.93a

0.11

2.63a,b

0.11

2.43 b

0.11

12.18�

��.06

Ever

repeatedclass

e1.89 a

0.03

1.89a

0.02

1.84a,b

0.03

1.74 b

0.03

3.74�

.02

Number

ofrepeatingclass

1.21

0.28

1.00

0.28

1.42

0.25

1.54

0.17

1.04

.04

Bodymass

index

16.57 a

0.27

18.03 b

0.32

16.21a

0.33

16.79a

0.31

6.06�

�.03

Physicalhealthf

1.29 a

0.58

1.30a

0.57

1.47a,b

0.70

1.51 b

0.67

4.12�

.02

Cognitive-em

otionalfunctioning

1.70 a

0.54

1.72a

0.54

1.95b

0.56

2.01 b

0.58

10.56�

��.05

Note.Scoreswithdifferentsubscripts

indicate

differencesatthep<.01significance

level

bySheffe’spost

hocanalyses.

aFvalues

andsize

effects(g

2)referto

theanalysesofcovariance,whichincluded

themain

effect

oftheresilience

classification,

withtraumaticevents

asacovariant.

bTheparentalmentalhealthproblemsscale

ranges

from

0(low)to

5(high).

c Theparentingpractices

scale,combiningboth

parentandchildreports,ranges

from

1(low)to

27(high)regardingsupportive

practices.

dOverallschoolgraderanges

from

1to

5,asreported

bytheteacher.

e Dichotomousvariable:1¼yes

and2¼no.

f Allhealthstatusscalesrangebetween1(low)and4(high)regardingproblemsandcomplaints.

� p<.01.��p<.001.��

� p<.001.

404

Concerning children’s early, antenatal, and perinatal health, the resilientchildren’s group had less antenatal maternal complications—v2(3, N¼616)¼ 9.62, p< .02—than traumatized children. In the traumatized group,5% of mothers reported pregnancy complications (e.g., high blood pressure,sugar level, or bleeding), whereas no complications were reported in theresilient group. Resilient children also had more normal birth weight thanother groups, but only among younger children of 6 to 11 years of age.The younger child group generally had significantly lower birth weight thanearly adolescents and adolescents, F(2, 616)¼ 5.01, p< .007; and theyounger resilient children less often had low (<2.500 kg) birth weight com-pared to the younger traumatized children (3.6% and 18.4%, respectively).The corresponding percentages were 10.9% in the younger spared and13.0% in the younger vulnerable children’s groups. Among early adoles-cents and adolescents, normal birth weight was not associated withresilience.

Gender and Developmental Age in Resilience

There were less girls than boys in the resilient group, whereas the gen-ders did not differ in traumatization. The resilience classification signifi-cantly differed according to age, F(3, 605)¼ 15.92, p< .0001 (g2¼ .07).Children were older in the resilient group (M¼ 11.82� 0.25) than inother groups (e.g., traumatized, M¼ 10.90� 0.24 and spared, M¼10.17� 0.20).

Significant interactions between resilience classification and gender speci-fied that mothers,’ F(3, 601)¼ 3.55, p< .01 (g2¼ .02), and fathers’,F(3, 617)¼ 4.68, p< .01 (g2¼ .02), mental health and extended family size,F(3, 601)¼ 2.49, p< .05 (g2¼ .01) were differently associated with thechildren’s resilience. Mothers and fathers had especially high levels ofmental health problems when the daughter was traumatized, whereas therewere no gender differences in other groups (see Figure 1 for fathers’ mentalhealth). In the resilient group, girls had a larger extended family(M¼ 10.02� 0.37) than boys (M¼ 9.56� 0.36), whereas in the traumatizedgroup, boys (M¼ 10.67� 0.38) had larger extended families than girls(M¼ 9.87� 0.36). Further, the body mass index was especially high amonggirls in the resilient group, as compared to boys and both genders in theother groups, F(3, 601)¼ 2.70, p< .05 (g2¼ .01). The developmental stageplayed a minor role in determining the role of resilience-fostering factors,as the Resilience Classification�Age interaction was significant only con-cerning the number of siblings, F(6, 593)¼ 2.23, p< .05 (g2¼ .02). Largefamily size was especially typical among adolescents in the vulnerable group,whereas age had no impact in other groups.


DISCUSSION

Despite the great burdens that war and violence place on child development,some children triumph over hardships and enjoy good mental health. Welack knowledge about how common children’s resilience is in wars andarmed conflict; and consequently, our estimations are often divided. War-affected children are regarded as either ‘‘surprisingly’’ resilient and invulner-able or as utterly traumatized and even lost. Child resilience in war is anemotionally loaded topic, often evoking guilt in parents and adults as theywitness children struggle in the face of horror and violence, and the emerg-ence of resilience often means great relief for us, the adults.

Our results suggest that about one-fifth (21%) of children could bedefined as resilient in conditions of armed conflict involving long-lastingmilitary occupation and life-threatening trauma exposure. This percentageis lower than is generally reported among war survivors, especially thoseexposed to terrorist attacks. There is an estimation that more than one-halfof the survivors of terrorism show resilience (Bonanno & Mancini, 2008). OfIsraeli adolescents, ‘‘only’’ 13% showed PTSD after personally experiencinga terrorist attack, and the others were considered resilient (Pat-Horenczyket al., 2007). Applying the classification approach to the study of resilienceprovides us with a more nuanced view of children who are struggling withthe consequences of trauma than solely regarding them as either resilientor traumatized. A follow-up study among American children with chronicfamily stress and adversities documented the prevalence of 22% resilient,7% vulnerable, 13% traumatized, and 58% spared children (Zucker et al.,

FIGURE 1 Child resilience and father’s mental health problems according to child gender.


2003). Here, it is interesting to note that the percentage of traumatized chil-dren in this study corresponds with this study and the percentage of trauma-tized children in the Israeli study by Pat-Horenczyk et al. In our sample, lessthan one-fourth (23%) of children belonged to the traumatized group (i.e.,both exposed to a high level of war trauma and suffering severe psychiatricdisorders). This contradicts the view, sometimes expressed in media, thatwhole generations living in war zones are considered traumatized, withthe definition based implicitly only on the exposure to trauma.

Factors Fostering Resilience

Family characteristics. Researchers agree about the nature of factors fos-tering resilience among children exposed to various kinds of adversity. The‘‘short list’’ reported among children suffering parental maltreatment, familyviolence, poverty, and trauma in peaceful societies includes good and lovingfamily relationships, intact parental mental health, and socioeconomic pros-perity, as well as normal cognitive development and emotional regulation(Luthar et al., 2000;Masten, 2007;Olsson et al., 2003).Our results generally con-cur, except for the nonsignificance of family socioeconomic status. As hypothe-sized, the resilient children enjoyed supportive and non-punitive parenting, andhadmentally healthymothers and fathers.The resilient children themselvesweregood at school, and showed high cognitive-emotional functioning. Also, theylacked somatic symptoms like excessive physical pain, and had good physicalhealth and normal pre- and postnatal histories.

We argue that the factors fostering resilience share common culturalcharacteristics, as family support and developmental achievements contrib-uted to resilience not only in the aforementioned research but in this study inthe context of armed conflict and Arab Islamic culture. Masten (2007)suggested that the secret of children’s resilience simply lies in the optimaloperation of ordinary human adaptation systems involving collective, fam-ilial, and individual domains. She referred to these fostering forces as ‘‘ordi-nary magic.’’ On the other hand, although similar family- and child-relatedfactors enhance resilience in adversity both in peaceful and war-torn socie-ties, there are also decisive differences in their content and meaning. The sig-nificance of optimal parental mental health and parenting practices mayserve as an example. The existence of ‘‘ordinary magic’’ in extraordinaryand life-endangering conditions demands remarkable balancing, buffering,and protective efforts, as this example of a family we interviewed illustrates:

. . . a group of Israeli soldiers entered by force one Palestinian home in which afamily of seven was living. The soldiers destroyed the furniture, threw the


kitchen tools and urinated inside those tools. They kept all the family in oneclosed room, not allowing the children to move anywhere, not even to toilet.When the children cried, the army officer opened the door and started toshout. . . .The siege continued for five days. The mother did her best to calmthe children by telling stories and fairytales to them, and asking them to drawtopics such as their recent picnics to the sea [italics added]. Yet, the mother feltas failing in the task of protecting her children because, as she said, the young-est children till now believe that the soldiers are still in the house, and they stillare clinging to parents, are afraid and fear sleeping alone.

This example offers a glimpse of the mother’s insightful parenting practicesaimed at buffering her children’s psychological stability by distracting theirattention from danger, focusing their memories in safe places, recalling joy-ful events, and simply trying to soothe their distress. Mentally healthy andcompetent parents are probably more capable of regulating their own fearsand providing a safe family atmosphere, despite the threats they face. There-fore, they can succeed in calming the frightened children and providingassurance of hope, safety, and recovery. A similar buffering process bymothers has been documented among Israeli families in the midst of shellingduring the first Gulf War, which, in turn, predicted children’s successfulrecovery from PTSD (Laor, Wolmer, & Cohen, 2001).

The previous illustration also reveals that the mother expressed feelingsof failure and despair, although, undeniably, she had made her best efforts,which were extraordinary and insightful. Her guilt feelings were due to thefact that she had not been successful in preventing her children from experi-encing the stressful events. There was no possibility for her children to beinvulnerable, but she could enhance their recovery, which can be consideredresilience (Hobfol et al., 2009). The feelings of guilt are similar to thoseobserved in Israeli families (Lieblich, 1978). Although good parentingpractice attenuates children’s fear and suffering, parents tend to blamethemselves for letting their children grow up in dangerous and hateful envir-onments, and they feel an overwhelming responsibility for the negativeimpact of war. Research confirms that restricting, anxious, and punitiveparenting styles are more common in trauma-affected families, reflectingboth parental concern as well as diminished energy or capacity to care(Barber, 2001; Punamaki, Qouta, & El-Sarraj, 1997).

Contrary to our hypothesis, child resilience was not dependent on thefamily’s socioeconomic status, indicated by parental education and econ-omic status. On the contrary, in the resilient group there were more fatherswithout formal education than in the traumatized group. This is unexpectedbecause it is generally agreed that families with high socioeconomic statusand well-educated parents possess resources and knowledge that enables


optimal child development (Conger & Elder, 1994). Safety, security andsense of trust, and parental availability are the primary sources of childwell-being, and their role becomes especially important in life-endangeringconditions of war and military violence. These mental, intimate, and spiri-tual characteristics do not necessarily depend on economic status, althougheducated parents are expected to share more knowledge about children’sneeds. Similarly, an earlier study among Palestinian families found thatuneducated mothers were especially able to protect their children’s mentalhealth in extreme life danger (Qouta et al., 2005). The authors speculatedthat higher parental, especially maternal, education can also bring negativeelements to parent–child relationships, such as absence from home and thepresence of work stress, which may interfere with the development ofchildren’s resilience.

Children’s characteristics. We found evidence that good health andconstitutional functioning were important for child resilience in militaryviolence and armed conflict. As hypothesized, resilient children were charac-terized by superior cognitive functioning, involving good capacity for mem-ory, problem-solving skills, and learning abilities. They also managed toregulate their emotions, be compliant and attentive during task perfor-mance, and showed no disruptive behavior. These results are importantfor two reasons: their academic success and recovery from war trauma.

Good academic performance is accepted both as a decisive determinantand consequence of child resilience. Our results concur with the findingson American children living in a violent, neglectful, and discriminatingenvironment (Fergusson & Horwood, 2003; Garmezy, 1990) and in adversefamily conditions involving violence and alcohol abuse (Zucker et al., 2003).The reason for academic success enhancing resilience is that it creates newsocial opportunities, increases self-esteem, allows compensatory experiences,and invites encouragement from significant adults (Pagani, Boulerice,Vitaro, & Trebley, 1999). Military violence and national strugglemay increase the importance of education and academic success. In thePalestinian society, high educational attainment can compensate for theparents’ political and national losses and humiliations (Garbarino &Kostelny, 1996). Well-performing children are likely to receive encourage-ment and admiration, which, in turn, can contribute to resilience.

Enriching and balancing cognitive-emotional processing of traumaticexperiences is a core element of interventions provided to children in armedconflicts. Cognitive-behavioral therapy (CBT) has been found to be effectivein reducing PTSD and other anxiety disorders and depression among trau-matized children in peaceful (Taylor & Chemtob, 2004) and war-time socie-ties (Peltonen & Punamaki, 2010). CBT facilitates cognitive-emotional and


symbolic processes and narrative capacities, and invites new and flexibleattributions and explanations of the effects of war-related stress. Resilienceresearch can contribute to the optimal choice and tailoring of theintervention methods.

As hypothesized, the resilient children had both better current health andmore optimal ante- and perinatal health. As compared to traumatized chil-dren, they were free of excessive pain, discomfort, and exhaustion; and theylacked general health problems. Currently, the Gaza Strip has been underinternationally supported Israeli siege and economic blockade since 2007,and there is an increased concern about the severe health consequencesdue to the shortage of medicine and food and the contamination of watersupplies (UN Office for the Coordination of Humanitarian Affairs, 2009).Our results contribute to that worry, as they show how important physicalhealth and sufficient nutrition are for children’s mental well-being and resili-ence. Sufficient body weight was especially salient among resilient girls, whoapparently need comprehensive mental and physiological resources duringtheir transition from childhood to adolescence. This result underscores theurgency for integrating nutritional, developmental, and general mentalhealth research, especially in armed conflicts that have lasted over genera-tions, such as this one in the Middle East.

Our findings suggest that early biological and constitutional strengths(i.e., non-problematic pregnancy and normal birth weight) were character-istic of resilient children, whereas traumatized and vulnerable children hadhad more risky pre- and perinatal history. This result coincides with otherresearch showing that maternal prenatal stress and anxiety can result inobstetric and neonatal problems that can amplify the vulnerability of infants(Caspi et al., 2002; Plomin, Asbury, & Dunn, 2001). In our study, we did notcollect data about maternal mood and distress during the pregnancy; how-ever, younger children (6–11 years) did more often have non-normativebirth weights, which, although speculative, may be explained by the fact thattheir mothers were pregnant during the very violent years of the FirstIntifada.

Concurring with general research on child gender and development, ourresults suggest that it was easier for boys to be resilient, whereas girls can bemore vulnerable when falling victim to severe trauma (Schaal, Elbert, &Neuner, 2009). Yet, unlike the gender differences found in other studiesof children under war conditions (Durakovic-Belko, Kulenovic, & Dapic,2003), Palestinian boys and girls were equally represented in the group oftraumatized children. Parental mental health problems were especially highamong traumatized girls, which again may reflect their greater sensitivitywhen facing both military trauma and family adversity. Our findings concurwith research on adults that unanimously regards women as more


vulnerable to PTSD and depression (Breslau, 2004). Finally, our resultsshowed relatively few gender-specific factors related to resilience either forfamilies or for children.

Concerning other demographic factors, older children were more oftenresilient than younger children. Village children were less often resilientand more often vulnerable than children from towns, refugee camps, andresettled areas. This result may reflect the fact that Palestinian children liv-ing in Gaza villages lack the social structure and ideological support that ischaracteristic of life in towns and especially in refugee camps. High vulner-ability may also refer to village children’s infrequent access to health careunder conditions of military siege and restricted movement. Because vulner-able children are easily forgotten in conditions of war and violence, we needto know more about the specific needs of vulnerable and traumatized groupsto be more effective in tailoring the assistance they receive.

Limitations of Our Research

Categorizing resilience as a typology is open to criticism due to the ambiguityabout choosing cutoff points of exposure to traumatic events. As there wereno children with zero exposure, we followed statistical and empirical knowl-edge for choosing the cutoff points. Concerning psychiatric symptoms, clini-cally critical thresholds were available, as there was a sufficient subgroup ofchildren without emotional and conduct disorders. The use of regressionmodels with interaction terms is often recommended when analyzing protec-tive, buffering, and moderating effects of variables (Baron & Kenny, 1986).This maintains linearity and is especially warranted when dealing with impre-cise categorization. Following that advice, we conducted a variable-basedanalysis of resilience. Yet, no hypothesized protective effect indicating resili-ence was found, although the main effects concurred with the results of theperson-based analyses. Our choice of a person-focused approach may alsobe criticized for not adequately depicting the phenomenon of resilience.Resilience is likely not an either=or phenomenon, but children may be resili-ent to varying degrees and in different domains of development. Further, inour ‘‘natural laboratory of danger and threat,’’ traumatized children mayhave been exposed to a higher level of traumatic events than the resilientgroup. Accordingly, we used traumatic events scores as covariants, whichhave moderated the problems caused by the typology method.

Our conceptualization of resilience as the absence of psychiatric disordersalso is open to criticism. Theoretically, resilience in traumatic conditionsdoes not only mean keeping one’s head above water, but also possibly blos-soming and finding positive experiences amid the chaos (Luthar et al., 2000).The next step in understanding preconditions of resilience in war should,


therefore, include positive emotions, happiness, posttraumatic growth, andempowerment as outcome variables.

Unfortunately, we had no possibility of following these Palestinian childrenlongitudinally, and lack knowledge of how stable their resilient or traumatizedstatuses are. Our cross-sectional procedure also prevents us from analyzinghow future developmental and traumatic experience would affect the differentgroups. A final criticism of our study is its very setting, which allowed us tolook only for individual and family characteristics of resilience. We need tomove toward a more comprehensive analysis of psycho-physiological,emotional, cognitive, and social processes that may explain resilience in a var-iety of extremely burdensome and dangerous situations such as war.

Contribution to Peace Psychology

An important question is whether children’s mental health in armed conflictis associated with their ability and willingness for reconciliation and empathytoward the enemy. War trauma is caused by the enemy, and it has been sug-gested that such suffering increases children’s aggressiveness and desire forrevenge. We could trace, however, only two studies confirming that severeexposure to war trauma was associated with increased aggressive behavioramong Croatian (Kerestes, 2006) and Palestinian (Qouta et al., 2008) chil-dren. Yet, the latter study revealed that loving and supportive parentingpractices could moderate the link between trauma and aggression. On theother hand, we have evidence that suffering and being a victim can also leadto peaceful activities and increased empathy. Historically, the Hibakushamovement provides an example; and in the Middle East, there are a numberof active peace groups composed of people on both sides of the conflict, suchas families who lost their children in war or individuals who have served assoldiers or been political prisoners (Abuelaish, 2011; see also http://cfpeace.org/). Empirical evidence is scarce on how personal exposure to war traumaand its mental health consequences are affecting children’s intergroup beliefsand attitudes toward peace. Thus, it is important that we extend the scope ofresilience studies to cover victims’ moral development, social psychologicalgroup dynamics, and political responses to armed conflict.

BIOGRAPHICAL NOTES

Raija-Leena Punamaki is a professor of psychology at the University ofTampere and the University of Helsinki, Finland. Her research focuses onpreventive interventions among trauma-affected children and infantdevelopment.


Samir Qouta is a professor of psychology at Gaza Islamic University,Palestine. He trains professionals in cognitive-behavioral therapy, andspecializes in child development in traumatic stress. Research topics includechild and family development and interventions among war-affectedchildren.

Thomas Miller is an associate professor at Queens University, Kingston,Canada. He specializes in clinical neurophysiology and rehabilitation.

Eyad El-Sarraj is a psychiatrist and human right activist. He is thefounder of the Gaza Community Mental Health Program, Palestine. Hisresearch specializes in impacts of war, military violence, and human rightsabuse on human development and well-being.

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who are the resilient children in conditions of military violence?

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