Growing number of Palestinian children with anxiety disorders

RAMALLAH - The number of children with post-traumatic stress disorder (PTSD) and other anxiety disorders including

Distressing memories

Children are doubly affected, sometimes by multiple traumatic events, by effects of trauma on their parents, care-givers in occupied Palestinian territories.

depression has increased in the occupied Palestinian territory where conflict continues with Israel, according to Médecins Sans Frontières (MSF) and Palestinian NGOs specializing in mental health.

Violations against Palestinian children related to the armed conflict between Israelis and Palestinians have been documented by the UN Children’s Fund (UNICEF) in Jerusalem, including patterns of killing and injuries, arrest and detention, ill-treatment and torture, displacement and denial of access to health and education services.

Children are doubly affected, sometimes by multiple traumatic events and by the effects of the trauma on their parents and care-givers.

MSF recently increased its number of clinics and staff training in developmental psychology to meet the growing needs of Palestinian children. Fifty-four percent of mental health patients at MSF clinics in the Gaza Strip were under 12 in 2010, it said. Over a third of the cases MSF treats in Gaza and over half in Nablus in the West Bank are severe, and affect the functioning of a person in daily life.

“More than half of consultations in Gaza and in Nablus are for children under 18 years old, so far in 2011,” said Hélène Thomas, psychological coordinator at MSF-France in Jerusalem.

“Children and adolescents have particular symptoms of psychological distress, like bedwetting, nightmares, learning difficulties [reading and speech], concentration and memory problems and therefore academic failure, or even aggressive behaviour,” said Thomas.

MSF provided 6,099 psychological consultations and treated 702 new patients in 2010 at their six centres in Gaza and one in Nablus, compared to 4,912 consultations in 2009.

“Nearly half of MSF patients under 15 years old in Gaza were treated for PTSD and nearly a third were treated for other anxiety disorders in 2010,” said Thomas, and “about a fifth of patients under 15 years old in Nablus were treated for PTSD.”

In Gaza, 74 percent of cases in 2010 came one year after a violent event. In Nablus a high level of anxiety cases (over 40 percent of all MSF patients) are diagnosed with anxiety related to settler harassment and military incursions.

“Children form an emotional association with symbols of a traumatic event,” said Thomas, “like when Israeli soldiers raid a home with dogs, and after the child develops a phobia of dogs, linking dogs to the event and fear associated with it.”

Mental health professionals from the Palestinian NGO Treatment and Rehabilitation Center for Victims of Torture (TRC), which provides comprehensive treatment and rehabilitation services to survivors of torture and organized violence across the West Bank, also reports that children seeking mental health care overwhelmingly suffer from PTSD and other anxiety disorders.

TRC treated 3,800 patients across the West Bank in 2010, about 15 percent of them children, and is partnered with Palestinian NGO Gaza Community Mental Health Programme in Gaza (GCMHP).

EMDR therapy

The TRC’s team of 36 psychologists and six psychiatrists say a popular form of psychotherapy - eye movement desensitization and reprocessing (EMDR), developed in the USA in 1987 - is proving successful in the Center’s treatment of children.

EMDR, often used in conjunction with cognitive therapy, creates bilateral stimulation (induced by, for example, eye-movements, tones or tapping) between the right and left sides of the brain during sessions to resolve the development of trauma-related disorders caused by exposure to distressing events, such as rape or military combat.

According to EMDR founder Francine Shapiro, when a traumatic experience occurs, it may overwhelm usual cognitive and neurological coping mechanisms. The memory and associated stimuli of the event are inadequately processed and dysfunctionally stored.

Psychologists from TRC and the East Jerusalem YMCA travelled to California in May to begin certification in EMDR training with Francine Shapiro. In about a year’s time TRC will begin to train Palestinian mental health professionals in EMDR techniques.

EMDR therapy aims to process these distressing memories, reduce their lingering influence and enable clients to develop coping mechanisms, says Khader Rasras, TRC executive director and clinical psychologist.

“I ask the child to recall the memories of the traumatic event in their minds, or for younger children the parent may recall the event,” explains Rasras, and “while reviewing the events chronologically the child follows my back-and-forth finger movements with their eyes.”

After Lina, eight-years old from Ramallah, witnessed her father forcibly removed by Israeli soldiers from the family home about a year ago she was diagnosed with acute PTSD. He remains in administrative detention, imprisoned without charge or trial.

Soldiers kicked in the door and began searching, recalls Lina, and when my father put his hands behind his head I held on to his leg. A soldier pulled me away by my hair, she says.

After Lina developed a stuttering problem, bed-wetting and lost weight, her mother brought her to TRC.

“Lina responds well when I tap on her right and left knees,” says Rasras. “EMDR is well suited for children since it is interactive, often with hand-games and drawing, and children do not have sophisticated memory networks."

Barriers to mental healthcare

Mental health professionals from GCMHP have yet to be granted permission by the Israeli authorities to exit Gaza for training. Under more than four-years of strict blockade, Gaza health professionals are rarely allowed to leave Gaza for training or education.

Cultural sensitivities are also a barrier to mental health care, although MSF reports that it is easier for parents to bring children for treatment, and often seek treatment themselves after they see results.

TRC head Rasras says he offers to place a barrier between himself and female patients, such as a handkerchief, when taping their hands or shoulders to help patients feel comfortable. Even then, the social stigma of mental health care in West Bank rural areas is often too great for many patients to continue treatment.

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