Individuals with PTSD compensate for such intense arousal by attempting to avoid experiences that may begin to elicit symptoms; this can result in emotional freezing, less interest in everyday activities and, in the extreme, may result in detachment from others.

Individuals with one or more PTSD symptoms are more likely to experience marital difficulties and occupational problems later in life and have poorer social supports. In the extreme cases PTSD may increase the risk for attempted suicide. War-related PTSD has been associated also with long-term consequences for mental health problems. The consequences that children face because of PTSD are severe. Children may regress into the earlier stages of development; they become apathetic with severe somatic, psychological, social, and functional problems.

For instance our research that we did in Palestine found that every child in the Gaza Strip had been exposed to at least three traumatic events. The most prevalent types of trauma exposure for Palestinian children were as follows: 99% of children had suffered humiliation (either to themselves or a family member); 97% had been exposed to the sound of explosions/bombs; 85% had witnessed a martyr’s funeral and 84% had witnessed shelling by tanks, artillery, or military planes. Importantly, our recent study found that 41% of children suffered from Post Traumatic Stress Disorders (PTSD). Overall, the exposure to chronic traumatic experiences led to an increase in the symptoms of PTSD among Palestinian children in the Gaza Strip.

The most prevalent types of PTSD were found to be: cognitive symptoms, from which 25% of children suffered (e.g., a child might take a long time to get to sleep, or feels everything around him is not safe); emotional symptoms from which 22% suffered (e.g., the child feeling alone and fearful, suffering from nightmares, bedwetting); social behavioural disorders, from which 22% suffered (e.g., aggressive behaviour, difficulty enjoying games); academic behavioural disorders, from which 17% suffered (e.g., difficult in concentration, bad academic performance); somatic symptoms, from which 14% suffered (e.g., headaches, stomach-ache).

Thus, having a normal childhood in war zones is unlikely and the psychological well-being future of these children is at risk of being compromised by on-going traumatic experiences.

Dr. Samara, in your professional opinion, adults who, when children, were exposed to the tragedy of war, whether in continuous intermittent periods, or in a one off experience, develop a greater propensity to experience fear, anxiety and hostility even when the experience is long over?

MUTHANNA SAMARA: People who go through traumatic experiences often have symptoms and problems as a consequence. How serious the symptoms and problems are depends on many aspects including life experiences before the trauma (e.g., negative life events, history of depression; previous exposure to trauma), personality, media exposure, the ability to cope with stress, the duration and severity of the trauma, and what kind of help and support a person gets from family, friends, and professionals immediately following the trauma.

It is often difficult to separate the effect of war trauma from that of potential compounding factors such as pre-migration stress, separation from family, post-migration stress, socioeconomic adversities, and acculturation difficulties.

The cumulative effect of multiple traumas is especially present in the situation of war. Research also indicated that there is a correlation between the number of previous traumatic experiences and PTSD, with more exposure leading to an increase of symptoms of trauma. In particular, research found a strong association between children and adolescents living with war who were exposed to war stressors and high levels of PTSD symptoms and grief reactions. While other studies indicated that the meaning of the violence is more important than the amount of violence directly experienced. It is also different whether children were the direct victims of violent events who will demonstrate greater PTSD levels than only witnessing violent events.

A study in Palestine showed that adults who were exposed to house demolition in Palestine showed a higher level of anxiety, depression, and paranoiac symptoms than those who only witnessed or those who hadn’t. The proximity of the child or adult to the event is thus an additional risk factor. Another example is that two years after the bombing, some children and adolescents who lived approximately 100 miles from Oklahoma City reported significant PTSD symptoms related to the event. This is an important finding because these youths were not directly exposed to the trauma and were not related to victims who had been killed or injured.

PTSD symptomatology was greater in those with more media exposure and in those with indirect interpersonal exposure, such as having a friend who knew someone who was killed or injured.

Longitudinal cohort studies confirmed that even after long periods of time after the war, victims with war-related PTSD were more likely than members of the general population to have depression, an anxiety disorder such as social phobia or persistent pain disorder.

Most individuals who develop PTSD experience its onset within a few months of the traumatic event. Individuals with one or more PTSD symptoms are more likely to experience severe problems in adulthood including marital and occupational difficulties and disability. Additionally, PTSD may increase the risk for attempted suicide as I mentioned before.

WONDERLANCER: In clinical, specific terms, how does violence engender violence?

DR. MUTHANNA SAMARA: Violence always leads to more violence. As I pointed out before children who were exposed to aggression directly or indirectly at home or at school settings whether by siblings, parents, peers will turn to be either violent towards others or the victim of violence. For example research revealed that those with criminal fathers and fathers who use violence as a mean of resolving conflicts at home were more likely to become violent and to be involved in more antisocial behaviour in their childhood, adolescence and adulthood.

According to the social learning theory, children will learn to use violence as a mean to solve conflicts as a consequence of their early exposure to violence either directly or indirectly. It has been proposed that bullying and violence is strongly influenced by parenting and family environment and may flow through the generations in a cycle of violence. For example, children’s bullying behaviours have been found to be related to harsh forms of discipline at home.

In a 22-year longitudinal study bullies at school were found to have a 25% chance of having a criminal record by the age of 30, which led to the ‘cycle of violence’ model. Also, adult males who bullied at school were at risk of having children who themselves bully others.

There is also evidence of an intergenerational transmission of these problems through both genetic and environmental channels. For instance, victimisation during mother’s childhood and domestic violence during her adulthood could influence her parenting ability and thus threaten children’s future health and wellbeing. Furthermore, homes with martial conflict and domestic violence are characterised by imbalance of power and aggression, consequently children develop a low empathy towards others and start to learn to dominate others and might even be encouraged in doing so. Domestic violence in this regard is relevant in explaining aggressive behaviour among children as a learned behaviour.

WONDERLANCER: Do we still have time to ‘save’ our children and thus our future as a species? What can be done once severe harm has been inflicted?

DR. MUTHANNA SAMARA: I am always optimistic in the sense that we always can change things. The massive increase of research in the area of children’s wellbeing is the bright side of the story. More research on these areas is required and especially more intervention programmes and evaluation of such interventions are really needed.

But this is going to be more difficult now especially with the current plan to massively cut down funds and grants especially to social sciences. The issue also is how those who are affected can have the courage to transform their emotional pain or harm into something good that will come of it. I think with the suitable diagnosis, assessment, support and intervention at the correct time and place would make things totally different and would help a lot to improve or cure even severe problems. Whether this possible or not, it is all related to the strong attitude and will of the affected person and those who are surrounding her or him.

WONDERLANCER: Another of your areas of research is the neurological development in extreme preterm children. What have been your main conclusions so far in terms of the direct correlation between diverse behavioural disorders and extreme preterm?

DR. MUTHANNA SAMARA: We investigated the behavioural consequences of extremely premature children (<=25 weeks of gestation) in comparison to their full term classroom peers at 6 years of age by using parent and teacher consensus reports about behaviour problems. Extremely preterm children at school age were significantly more likely to have behaviour difficulties, including problems in a range of domains such as emotion, conduct, hyperactivity, attention, peer relationships, and prosocial behaviour compared to full term classroom peers.

Furthermore, parents and teachers agreed that, for 23% of the extremely preterm children, these behaviour problems had a considerable impact on home or school life, compared with only 7% in the comparison group, and on school adaptation. Controlling for general cognitive performance allowed us to determine whether differences in behaviour and school adaptation could be explained by low IQ alone or were attributable to specific deficits in behavioural or emotional regulation.

We found that low IQ explained the differences in some behaviour domains such as conduct, hyperactivity, and impulsiveness and their impact on parents and teachers. This indicates that for these behaviours this seems to be the consequence of global changes in cognitive functioning and not a specific feature of development after preterm birth. On the other hand low IQ did not account for the differences between extremely preterm and control in relation to emotional and attention problems and difficulties in peer relationships or school adaptation. Problems with maintaining and regulating attention seem to be a specific deficit in extremely premature children. Furthermore, it could be that some problems that are common amongst extremely premature children such as having poorer motor abilities and poor somatic growth can lead to victimization.

In a different study on the same population we also found that eating problems were more common among extremely preterm children at 6 years of age than the full term comparison group, including oral-motor and hypersensitivity problems. These eating problems were only partly related to other disabilities such cognitive, neuromotor and behavioural and make an additional contribution to continued growth failure and thus require early recognition and intervention.

WONDERLANCER: On what area of research are you currently focusing your study efforts, and what previous observations have led you to direct your attention to this area?

DR. MUTHANNA SAMARA: One of the new areas of research I’m now focusing more on is cyberbullying, which is bullying through electronic means such as networked computers and mobile phones. Cyberbullying is increasing
and at present a high profile concern for policy makers, schools, teachers, parents, media and communities across the world. The danger of such behaviour is the difficulty for the victim to escape from it, the huge potential audience, and the anonymity of the bully who may be unaware of the consequences of his or her actions. It is very important to design suitable intervention programmes for this kind of bullying.

WONDERLANCER: Dr. Samara, thank you again for your invaluable collaboration. We hope and wish for the very best on your research efforts, just as we hope for the very best for our children’s future: OUR FUTURE.



Dr Muthanna Samara’s Profile at Kingston University (London) >

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