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 Who Are the Resilient Children in Conditions of Military Violence? Family- and Child-Related Factors in a Palestinian Community Sample Raija-Leena Punama¨ki Department of Psychology, School of Sciences and Humanities University of Tampere, Finland Helsinki Collegium for Advanced Studies University of Helsinki, Finland Samir Qouta Department of Psychology Islamic University of Gaza, Palestine Thomas Miller Hand and Upper Limb Centre, St. Joseph’s Health Care Queen’s University, Kingston, Canada Eyad El-Sarraj Gaza Community Mental Health Program, Palestine The prevalence of resilience in the presence of military violence and the role of child and family characteristics fostering that resilience were analyzed in a Palestinian 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 medical examination 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 Punama¨ki, Department of Psychology, Helsinki Collegium for Advanced Studies, University of Helsinki, P.O. Box 4 (Fabianinkatu 24), FIN-0014, Finland. E-mail: 390 PUNAMA¨ KI, QOUTA, MILLER, AND EL-SARRAJ status on somatic, sensory, and cognitive domains. The results revealed an equal 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 parental mental health, supportive parenting practices, good school performance, superior cognitive functioning, good physical health, high body weight, and normal birth weight. Variable-based analyses revealed no support for the hypothesis that these family- and child-related factors protect child mental health, although their direct association was confirmed. The discussion focuses on mechanisms fostering child resilience in war zones. Attempts to win wars are not accomplished by using superior high-tech weaponry, military arms, and personnel alone. The social and psychological destruction of targeted communities are increasingly prevalent in modern warfare. Children and their families are becoming direct targets in armed conflicts, and what was usually regretted as ‘‘collateral damage’’ has, in some cases, become accepted war doctrine. For instance, the Dahia doctrine, endorsed by the Israeli Defense Force, uses indiscriminate and dis- proportionate power to cause immense damage and destruction to the adversary’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 to severe adverse and traumatic experiences, do not suffer from significant mental health problems. Some of these children may even show high devel- opmental competence and even become emotionally stronger following the trauma (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 factors contributing to resilience in a war context. This study focuses on the pre- valence of resilience and on family- and child-related factors that foster resilience among Palestinians living in the midst of armed conflict. NATURE OF RESILIENCE Resilience as a dynamic link between adverse conditions and psychosocial adjustment has been conceptualized either as a category—individuals who, despite exposure to severe adversity, show relatively high competence—or as a buffering factor that protects child health and developmental competence from the negative impact of trauma (Shaffer, Burt, Obradovic, FACTORS FOSTERING RESILIENCE 391 Herbers, & Masten, 2009). We could not find studies applying a categorical approach to child resilience in armed conflict, although increasing research is 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 posttraumatic stress disorder (PTSD). For example, one study documented that 63% of survivors of a terrorist attack were resilient as measured by the absence of psychiatric disorders (Bonnano, 2004). Similarly, resilience among children in armed conflicts is commonly described as those children who show competence 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 the adaptation skills related to the particular traumatic stress (Luthar & Cushing, 1999; Masten, 2007). Children living in armed conflict situations have the dual challenge of securing both their physical and emotional sur- vival while trying to accomplish normative development. The evidence is clear that accumulation of severe war trauma increases the likelihood of children’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 define resilient children in armed conflict as those who are exposed to severe loss, atrocity, and destruction, and yet lack psychiatric disorders. In other types of 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 find compensatory social experiences and extra-familial safety (Zucker, Wong, Puttler, & Fitzgerald, 2003). Resilience in the academic domain may be significant for children living in poor, violent, and deprived communities because 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 of resilience suggested by Werner and Smith (1982), depicting the balance between the severity of trauma and emergence of mental health problems. A 22 grid was created to categorize children according to the severity of their personal exposure to military trauma (high or low) and the presence or absence of emotional and conduct disorders. This resulted in four groups of children: resilient (high trauma exposure and absence of disorders), trau- matized (both high exposure and presence of disorders), vulnerable (low trauma exposure, but presence of disorders), and spared (both low exposure and absence of disorders). The resilience classification is presented in Table 1 392 PUNAMA¨ KI, QOUTA, MILLER, AND EL-SARRAJ TABLE 1 Conceptualization of Resiliency as a 22 Classification of Trauma and Psychiatric Disorders Emotional and conduct disorders Absence of disorders Presence of disorders (none of the 3) (1 to 3) Exposure to traumatic Low exposure Spared children Vulnerable children events (2–5 events) High exposure Resilient children Traumatized children (6–18 events) RESILIENCE-FOSTERING FACTORS Child resilience has been attributed to compensating social and individual factors related to community, family, and the children themselves. Empirical evidence elucidates explanatory factors for resilience among children living in poverty (Fergusson & Horwood, 2003; Garmezy, 1990), family violence and 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 a respectful and stimulating learning atmosphere, with families characterized by high cohesion, secure bonding, and authoritative and supportive parenting styles (Masten & Coatsworth, 1998; Olsson, Bond, Burns, Vella- Brodrick, & Sawyer, 2003). Resilient children themselves are able to process stressful and traumatic experiences by seeking realistic causal explanations without being overwhelmed by guilt and fear (Beardslee & Podorefsky, 1988). Also, they show curiosity, prosocial attitudes, and a willingness to create novel, flexible solutions to problems (Masten et al., 1988; Zucker et al., 2003). Despite observations of resilience among children living in armed con- flicts, relatively few studies have empirically examined factors that may explain 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 such as PTSD and depression (Bonnano, 2004). Stichick Betancourt and Khan (2008) identified multiple ecological layers of protective processes in the lives of war-affected children in acute and post-war settings. Social and FACTORS FOSTERING RESILIENCE 393 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 Palestinian children from depressive (Barber, 2001) and aggressive (Qouta, Punama¨ki, Miller, & El-Sarraj, 2008) symptoms in life-endangering conditions of mili- tary occupation. Loving and supportive parenting was further associated with children’s creativity and cognitive capacity, which, in turn, contributed to good psychological adjustment, despite severe trauma exposure (Punama¨ki, Qouta, & El-Sarraj, 2001), suggesting that motivational and cognitive-emotional functioning might be the mechanisms through which good parenting fosters resilience. One study confirmed that social support and optimal caregiver relationships promoted resilience among refugee children fleeing armed conflict (Hodes, Jagdev, Chandra, & Cunniff, 2008). Intact maternal mental health has been documented as one of the main ‘‘secrets of resilience’’ in many wars, including in former Yugoslavia (Smith, Perrin, Yule, Hacam, & Stuvland, 2002) and the Middle East (Qouta, Punama¨ki, & El-Sarraj, 2005). Finally, a sensitive mother–child relationship that enhances secure attachment can protect the offspring across their lifespan (Kanninen, Salo, & Punama¨ki, 2000; Mikulincer, Horesh, Eilati, & Kotler, 1999). Individual characteristics and protective factors that may predict child resilience in armed conflicts are pre-trauma strengths and resources such as constitutional health and temperamental characteristics of curiosity and balanced emotionality, flexible and creative cognitive-emotional processing of 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 promote resilience both in general (Cicchetti et al., 1993; Luthar et al., 2000) and in armed conflicts and wars. A Lebanese study showed that children with soph- isticated problem-solving skills, high self-efficacy, and high intelligence were at 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 protected Palestinian children’s mental health from negative trauma impacts (Qouta, Punama¨ki, & El-Sarraj, 2001), and predicted low PTSD and depression in adolescence (Punama¨ki, 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 role of early optimal caregiving relations in fostering resilient development, despite adverse conditions, as they provide compensatory effects on 394 PUNAMA¨ KI, QOUTA, MILLER, AND EL-SARRAJ neurobiological deficiencies (Bradley et al., 1994; Curtis & Nelson, 2003). Pregnancy- and birth-related risks predict long-term developmental and health 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 evidence of impacts of famine during pregnancy on children’s future vulnerability to obstetric problems and various somatic illnesses (Susser, Brown, & Matte, 1999), and traumatic exposure to the 9=11 terrorist attacks has been found to have negative impacts on pregnancy outcomes (Mulherin Engel, Berkowitz, Wolff, & Yehuda, 2005; Yehuda & McEwen, 2004). Resilience research in armed conflict has, however, ignored good somatic health and optimal constitutional and neuropsychological functioning as possible contributors to resilient child development. STUDY OF RESILIENT CHILDREN Aims of the Study The aims of this study are to examine the prevalence of resilience among children 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 higher parental education, and the parents have better mental health and use more supportive and non-punitive parenting practices. The resilient group is expected not to differ from the spared children (low exposure and absence of disorders) in these family characteristics. Second, compared to the trau- matized group, we hypothesize that the resilient group of children do better at school and, third, have better early and current health status (i.e., less ante- and perinatal complications such as low birth weight and current high body weight and good health). Fourth, we hypothesize that the resilient group 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 group in these individual characteristics. Furthermore, we examine whether the role of resilience-fostering family- and child-related factors differs in regard to (a) gender, (b) developmental stages (middle childhood, early adolescence, and adolescence), (c) age, (d) place of residence, and (e) family size. FACTORS FOSTERING RESILIENCE 395 METHOD Participants This study utilized the dataset collected on 640 children from the Gaza Child Health 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 early adolescence (12–13 years), and 20.9% were adolescents (14–16 years). There 2 were no gender differences in age groups: v (2, N¼640)¼ 3.44, p¼ ns. Information about children’s mental health, family issues, and traumatic experience was collected using in-depth questionnaires completed by the youth group (age 12 and up) themselves and by the children’s and youths’ parents and teachers. Also, a physical health examination was conducted on 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 children completed the physical examination because of the practical difficulty of reaching them during the occupation. The random sample reflects the social status distribution on the Gaza Strip during the Palestinian Authority rule after the Oslo Agreement. With respect to parent education, no formal education was reported in 13.8% of mothers and 8.6% of fathers, and 20.3% of mothers and 25.2% of fathers had an elementary education (Grades 1–6). About one-fourth of both mothers (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%). The mean number of people living in each household was 9.70 (2.95), and the mean 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 refugee camps, one-fifth (20.6%) in villages, and 8.5% in resettled areas that are extensions 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 to indicate the job category of the main income earner and the number of months that person had worked full time in the past 1 year. This income level distribution in the sample was divided into upper (professionals, 396 PUNAMA¨ KI, QOUTA, MILLER, AND EL-SARRAJ 19.6%), middle (skilled laborers 30.8%), and lower (unskilled laborers, 49.6%) social classes. Estimates of income level were utilized instead of direct inquiry, which was not considered proper. Study Design A two-stage random sampling design was applied. In the first stage, a list of all schools on the Gaza Strip was created. From that list, schools were strati- fied based on geographic location (town, refugee camp, village, or resettled area). Second, a list was prepared that included all of the pupils in those schools. That list was stratified according to gender and age, and the allo- cated number of students from each geographic location was randomly selected from that school list. The address of the student was obtained from the school, and the interviewers then met the parent or main caregiver of the student to obtain consent to participate in the survey. At that time, an intro- ductory letter was presented to the parents or main caregiver describing the purpose of the survey and requirements of the research. Consent was obtained by verbal approval from the parents or main caregiver for the child participating 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 informant in the majority of cases (76.0%). The father reported in 16.1% of cases; and in 7.9% of cases, the informer was another family member (aunt, uncle, etc.). A female pediatrician and a female nurse conducted the physical health examination in the school buildings. An authorization letter obtained from the Palestinian Authority Minister of Education facilitated the researchers’ access to the schools. Translation of the questionnaire was conducted by members of the Palestinian research team, who are all fluent in English and Arabic. The questionnaire was translated from English to Arabic, and then indepen- dently back-translated to English. Comparison of wordings and concepts were discussed among the research team, and any differences were resolved by consensus. Special attention was paid to ensure that key phrases were expressed in colloquial Arabic specific to Gaza. The questionnaire was pilot tested 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 on the main instruments in the survey in 25 households. The questionnaires were administered 1 week apart. The intraclass correlation of each of the instruments ranged between 0.77 (Parent Form for Emotional Disorder) and 0.89 (Teacher Form for Emotional Disorder). FACTORS FOSTERING RESILIENCE 397 Measures Demographics. Demographic factors included the father’s and mother’s education (no education, preparatory and primary school, secondary edu- cation, and university), family income status (high, middle, or low), place of residency (refugee camp, town, village, and resettled area), and family size. Traumatic events. The exposure to military violence was assessed by an 18-event list modified from the War Trauma Questionnaire by Macksoud and Aber (1996). It covers events of direct physical violence targeted at the child (e.g., beaten, chased by soldiers, and bullet wounds) or indirect or witnessed events to a close person (e.g., witnessing killing or wounding of a family member or friend), psychological violence (e.g., verbal threats or preventing access to health services), material losses (e.g., home demo- lition), and arrest and detention of the child or family members. The parents and the child were asked whether the child had been exposed to each of these events during the First Intifada (0¼no and 1¼yes). If the answer was yes, then they were also asked to estimate how many times that exposure had occurred during the child’s or adolescent’s lifetime. A sum variable was constructed by accounting for the occurrences of the traumatic events, ranging between 2 and 18 in this sample. Unfortunately, there were no children with zero exposure, and constructing a dichotomous variable for a 2 2 grid for resilience classification is problematic. The traumatic events variable was dichotomized to indicate low (2–5 events) and high (6–18) levels of traumatic events, using the median split as a cutting point. The mean score was 5.6 (2.38) in the sample. The decision of the cutoff point is based on both empirical statistics and contextual analyses of the phenom- enon (Luthar & Cushing, 1999). Earlier research among Palestinian children has shown a threshold, rather than a dose-effect, of trauma impact on mental health problems, the critical accumulation being five to six events (Garbarino & Kostelny, 1996). Emotional and conduct disorders. These were measured using the Ontario 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 (3rd ed.; American Psychiatric Association, 1980) criteria, and consists of 34 questions that measure three mental health disorders: conduct disorder, emotional disorder, and attention deficit hyperactivity disorder. The parents and teachers were asked to rate how well the items describe the child’s 398 PUNAMA¨ KI, QOUTA, MILLER, AND EL-SARRAJ behavior on a 3-point Likert scale now or within the past 6 months; the scale ranged from 0 (never true), 1 (sometimes or somewhat true), to 2 (often or very true). The cutoff value for the resilience classification was absence or presence of disorders, and a dichotomized variable was accounted for: values were 0¼ absence of disorder indicating no conduct, emotional, and hyperactivity disorders (55.5% of children) and 1¼presence of disorder indicating 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, three sum variables were constructed to indicate emotional, conduct, and total disorders by combining parents’ and teachers’ linear scores. Resilience classification. This was constructed according to Werner and Smith (1982) and Fergusson and Horwood (2003), referring to children who had been exposed to severe trauma, but show absence of psychopath- ology. The cross-tabulation of the dichotomized variables of traumatic events and psychiatric disorders resulted in four groups (see Table 1): spared children (low exposure to traumatic events and absence of psychiatric dis- order), vulnerable children (low exposure to traumatic events and presence of psychiatric disorder), resilient children (high exposure to traumatic events and absence of psychiatric disorder), and traumatized children (high exposure 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 whether they had the following experiences in the past year (yes¼ 1 and no¼ 0): seeking help for nervous or emotional problems, being often sad or depressed, feeling incapable to cope with stress, receiving medication for emotional problems, and hospitalization for psychological problems. Separ- ate sum variables were formed for mothers and fathers, ranging between zero and five. Parenting practices. These were assessed by a nine-item scale (Barber, 2001) indicating parents’ approaches to discipline in a situation where the child 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., calmly discussing the problem). Parents evaluated their own behavior toward the child, and youth separately reported their mother’s and father’s behavior toward 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 quality of parenting practices was constructed, which had moderate reliability