The Invisible Wounds of Palestinian Children

Abdulrahman Mhammad standing next to his older brother Karam Muhammad

Photo courtesy of Mimi Farajallah

COMMENTARY

Palestinian children in the Gaza Strip experience complex continuous trauma (CCT), which refers to prolonged and repeated exposure to multiple traumatic events or experiences, often at the beginning of early childhood and continuing over an extended period of time. Unlike single traumatic incidents, CCT involves ongoing and cumulative stressors that can overwhelm an individual's ability to cope and adapt.

CCT can have profound and lasting effects on various aspects of a child’s psychological, emotional, and social functioning, often resulting in complex posttraumatic stress disorder (C-PTSD) symptoms and difficulties in forming healthy relationships or maintaining a sense of safety and stability. C-PTSD presents a broader array of severe symptoms, including emotional dysregulation, difficulty in relationships, negative self-perception, disturbances in self-identity, hypervigilance, avoidance behaviors, flashbacks, physical symptoms, trust and intimacy issues, and a sense of helplessness and hopelessness.

The living environment for Palestinian children is characterized by chronic adversity such as poverty, war, personal injury, blockade, starvation, destruction of homes, loss of family members who have been killed, loss of sense of security, loss of community, and more. Gaza's economy has been crippled, with high unemployment rates and limited opportunities for economic growth. As for education, schools have struggled to function due to the lack of resources and infrastructure. Gazans even face shortages of the basic needs of clean water, electricity, and adequate housing.

Through continued bombing, starvation, mass killing, and destruction of all basic foundations for life in the Gaza Strip, there is a universal sense of helplessness and hopelessness about the future among Palestinians, where the individuals may feel trapped in their circumstances and struggle to envision a positive outcome. This is not a new policy; it began in 2007, with many subsequent years of blockading Gaza. The blockade restricts the movement of individuals and goods in and out of Gaza, severely limiting Palestinian access to essential resources such as food, medicine, fuel, and building materials. The blockade also destroys the Gaza health care foundation. Hospitals and medical facilities face severe shortage of essential medicines, equipment, and electricity.

Palestinian children in the Gaza Strip have experienced the impacts of several military offenses spanning from 2008 to 2024, leaving the region ruined. Additionally, a 17-year blockade imposed by both Israel and Egypt has significantly diminished the quality of life in Gaza.

Research
A survey conducted by Save the Children in 2018 that included 150 young adolescents with a median age of 14, along with 150 caregivers residing in the Gaza Strip, concluded that 95% of Palestinian children exhibit mental health challenges such as depression, hyperactivity, a tendency to isolate themselves, and aggression. The study highlights the comprehensive effects—physical (including death, destruction, and injuries), and psychological (such as PTSD, depression, and anxiety). The survey also revealed that youth unemployment has soared to 60%, and poverty rates have surged to 30% to 50%. A staggering 68% of children report struggling with sleep disturbance, with 78% identifying the sound of warplanes as their primary source of fear.^1,2

In an interview with Dr Kamal Qadih, he summarized the psychological suffering of Palestinian children in Gaza:

I can confirm that an overwhelming majority, approximately 90 to 95%, of Palestinian children are in need of extensive psychological assistance. This type of support cannot be adequately provided in a brief time frame; it necessitates long-term therapy spanning three to five years to effectively address and restore the mental health of these children. In my experience working with Palestinian children at our clinic, it is evident that they grapple with various behavioral, psychological, mental, and emotional challenges. Despite our best efforts with the resources available, as we strive to offer as much psychological aid as possible, regrettably, that remains insufficient due to limitations.

In a 2022 report titled "Trapped" by Save the Children, a significant rise in the number of children expressing emotions of fear (84% compared with 50% in 2018), nervousness (80% compared with 55%), sadness or depression (77% compared with 62%), and grief (78% compared with 55%) was observed.³

Suicide

The report also highlighted that over half of Gaza's children have considered suicide, and 3 out of 5 are engaging in self-harm. Extreme behaviors among Palestinian children, such as attempted suicide, stem from feelings of hopelessness and unacknowledged trauma. These behaviors can serve as a message of protest and rejection of the horrific reality of everyday terror, destruction, loss of loved ones, and loss of all elements of life in their community.

Seventeen-year-old Islam al-Maqdisi, a resident of Al-Bureij camp, tragically set himself on fire due to dire poverty conditions living below the poverty line. Since childhood, he diligently worked in the cemetery, tending to graves in order to support his sick mother and siblings, ensuring their basic necessities. However, circumstances worsened when he sought aid from a charitable organization to alleviate their starvation. Regrettably, during his visit, he appropriated canned food without permission, leading to accusations of theft by the organization. Overwhelmed by shame, Islam resorted to self-immolation, resulting in his untimely death. Similar tragedies occurred in other families like the Abu Hujair and Abu Khoussa families in the Gaza Strip, highlighting the devastating impact of poverty and the adverse conditions imposed by Israeli policies and wars on the Gaza Strip. Such incidents underscore the harsh psychological toll inflicted on Palestinian children, precipitating desperate acts like suicide.

In an interview with Palestine Today News, Samir Zaqout, Deputy Director of Al Mezan Center for Human Rights, elaborated on the root causes behind the suicide cases in the Gaza Strip. Zaqout attributed these tragic incidents to the pervasive issues of poverty and unemployment, which have inflicted significant hardships and burdens on the people of Gaza. Furthermore, he emphasized that these challenges have led to economic strains and triggered a cascade of social and psychological problems within the community.⁴

Dr Yasser Abu Jamea, director of the Gaza Mental Health Program, emphasized that suicides in Gaza stem from an amalgamation of economic, social, and political crises, fundamentally distinct from those in countries enjoying security, stability, and freedom of movement and travel. In Gaza, they serve as poignant messages of dissent and resistance against the harsh reality endured by its residents.⁵

Resilience

Despite facing overwhelming challenges, Palestinian children have demonstrated remarkable resilience in coping with their mental health issues. With limited access to mental health services and resources, these children rely on their families, communities, and cultural practices to find support and solace. They engage in storytelling, art therapy, and community gatherings to express their emotions and build resilience in the face of adversity. A study examined the impact of Israeli military escalation on Palestinian children's mental health, particularly PTSD, anxiety, and resilience. It highlighted the complex link between mental health challenges and resilience in this group. Results showed that 92.4% of Gaza's Palestinian children felt secure with their caregivers.⁶

Palestinian children staying in a shelter at a UN school

Photo courtesy of Hanan Farajallah

Palestinian children who survived the Israeli 2014 military offense were able to cultivate a form of resilience through the psycho-social coping support they received within Palestinian society. Strong family bonds played a significant role in fostering resilience among the participants. For instance, the 3 brothers Musab, Omar, and Mohammed Wahdan from Beit Hanoun, who lost family members, including their mother, and suffered injuries during the 2014 offense, had members of the broader Palestinian community providing crucial support to them. When the 3 children required medical treatment in Turkey for their war injuries, distant relatives from another town accompanied them, highlighting the importance of familial support networks.

Testimonials

The current (2023-2024) Israeli offense in the Gaza Strip continues to crush Palestinian society and instill a sense of hopelessness among its population, including children. The widespread destruction, loss of life, and displacement exacerbated the mental health crisis among Palestinian children. The indiscriminate targeting of civilian infrastructure, including schools and hospitals, further traumatized children and left them feeling abandoned and vulnerable. The living environment Palestinian children are living in is highly characterized by chronic adversity such as poverty, blockade, starvation, destruction of homes, family being killed, loss of sense of security, loss of community, personal injury, and much more. The surviving Palestinian children witness the death of family members, the destruction of their homes, and the constant fear of violence, leading to profound psychological trauma. Thousands of surviving children became orphans when their parents were killed, and some of them had no surviving family members.

The destruction of the familial support networks that provided instrumental support during the previous Israeli military offenses pose significant challenges to children's coping mechanisms, which were tragically severely disrupted during the current (2023-2024) crisis. The very life of these children is threatened by the rising malnutrition in the Gaza Strip due to the alarming lack of food, water, and health and nutrition services stemming from indiscriminate military actions.

According to the World Food Programme, 1 out of every 6 children under age 2 suffers from acute malnutrition, while 95% of households are restricting meal portions and sizes.^7,8

After witnessing his father and uncle being killed by an Israeli bombing, 3-year-old Abdul Rahman Muhammad turned to his grandmother and asked her: “My uncle has no head. Who killed my father? Where did he go?” Abdul Rahman posed numerous questions to his grandmother following his father’s passing. He asked, “Where is my father? When is he coming back home?” The grandmother replied, saying, “Your father is in heaven.” He asked, “Where is heaven?” His grandmother replied, “He is in the heavens with God.” The surprise came in Abdul Rahman's response: “Grandma, ask God to return my father to me; I want to sleep next to him.” Abdul Rahman posed these questions to every person he met, seeking answers and yearning for his lost father. What lasting impact will this suffering have on Abdul Rahman's long-term psychological well-being?⁹

Adnan Al-Kafarna, a 7-year-old boy currently residing in a UN school shelter in Deir Ulbalah, recounted the tragic killing of his father. “They killed my father when he went to buy food for us from the market.” Adnan pleads with his mother persistently, urging her not to go to the market out of fear that she might suffer the same fate. He says that he wishes he had been with his father, sharing his fate alongside the rest of his family so that the pain would not continue. This anguish inflicts significant psychological distress on Adnan.⁹

Twelve-year-old Alaa said: “We were displaced from the North of Gaza because of the fear and destruction we experienced, where death was everywhere, to move to the central region of the Gaza Strip after the Occupation warned us and claimed that the central region was safer. Here, we had to pass through the checkpoint filled with tanks, and I listened to what the soldiers said through the loudspeakers. ‘Raise your hands, and it is forbidden to look left or right.’ We watched how they shot and killed people.” Her mother described her child's condition: “My child was terrified. Her hand remained cramped for 5 days. She was presented to the doctor for treatment and was told that what she was experiencing was due to a state of fear and trembling. My child still suffers from a psychological disorder and is seen by a counselor at the shelter center.”⁹

Ten-year-old Muhammad said, “I woke up to the screams of the neighbors and the sound of the house being bombed, so we fled from our house and headed towards Al-Shifa Hospital to search for a safe place. Five days later, the hospital was bombed.” His mother expressed concerns about her child's current psychological health challenges, including issues like involuntary urination, withdrawal from family, depression, anxiety, and an overwhelming fear of various stimuli, such as loud noises. Additionally, Muhammad struggles with insomnia, a pervasive sense of fear, and displays a strong attachment to his parents.⁹

Five-month-old Karim Ahmed Abu Amra is among the countless children enduring the harsh realities of life in Gaza, where the ravages of chaos persist. Living in a family deprived of even the most basic necessities, Karim faces the dire challenge of inadequate nutrition. His mother, unable to breastfeed due to malnourishment, struggles to provide him with the vital sustenance he requires. Despite their efforts to procure baby formula, financial constraints and scarcity prevent them from obtaining it most days. The absence of proper nourishment for both mother and child jeopardizes Karim's very existence.⁹

Khaled Muhammad Abu Saada's mother is in utter despair—her 3-and-a-half-year-old child has passed away. They sought refuge in a shelter at the UN school following the bombing of their home in the Bureij refugee camp. However, Khaled is now absent from her side. Overwhelmed by grief, she broke into tears as she speaks of Khaled's death, saying: “Because of the siege, the war, the lack of food, and the lack of milk and treatment, they killed my child. The joy of my life died, and my heart is in agony.” She continued, "Every time, Israel bombed and struck with its planes, which never stops, Khaled would scream, become afraid, and wake up terrified.”⁹

Ahmed Muhammad Abu Saada, born during the Gaza war, is Khaled's 4-month-old brother. Now, he too faces shortages of baby formula and diapers. His mother fears that Ahmed may suffer the same fate as his brother Khaled. “I question how long this situation will continue. I would not wish this on my worst enemies. What is the fate of our children going to be?”⁹

Concluding Thoughts

In the Gaza Strip, Palestinian children bear the brunt of wartime hardships. They endure profound fear and uncertainty as their homes are bombed and demolished, leaving them without shelter or security. Many have lost 1 or both parents or even their entire families, depriving them of crucial support systems. Their days are marred by the relentless onslaught of explosions, shelling, and smoke, erasing any semblance of beauty from their lives. These children are no strangers to the horrors of occupation and oppressive policies, which inflict deep and enduring trauma. Fear and death have become constant companions, stealing away their innocence and robbing them of the fundamental right to a safe and fear-free childhood.

In Gaza, it is unrealistic to anticipate significant progress in psychological well-being or in the development of psychological programs without a political resolution that grants Palestinians the right to self-determination. This issue is fundamentally political. Ending the Israeli Occupation is indispensable for initiating the healing process and enabling Palestinian children to rebuild their lives. It represents the crucial first step in their journey toward recovery and empowerment.

As mental health clinicians, our primary focus should be on equipping Palestinian children with coping mechanisms and implementing effective interventions for those impacted by war. Our approach must prioritize comprehensive support systems, trauma-informed care, and strategies for fostering resilience. We must strive to offer psycho-social support and educational resources, aid in family and community reintegration, to address basic needs, and promote resilience. However, the ongoing relentless assault on Palestinian society, particularly its children, severely undermines our efforts to address children mental health challenges. Each time Palestinian children attempt to confront their trauma and seek assistance; they are met with yet another wave of Israeli military aggression.

Dr Farajallah is a psychologist based in California. She is also the founder of Iman Network, a nonprofit offering clinical treatment, education, and research for mental illness. Dr Farajallah is a respected researcher and writer, focusing on topics such as the impact of war on children's mental health. She has published articles on various issues, including trauma in war zones, the effects of occupation on Palestinian children and women, and coping with pandemics. Dr Farajallah also conducts training on PTSD and trauma. She is the author of a soon-to-be-released book (My Life Is a War: voices of Traumatized Palestinian Children Under Israeli Occupation). She also has directed films like “Gaza's Children: Innocence Lost” and the soon-to-be-released “My Life is a War: I Want to Live in Peace.”

References

1. Generation of children in Gaza on the brink of a mental health crisis, new research shows. Save the Children Canada. June 4, 2018. Accessed March 26, 2024. https://www.savethechildren.ca/article/generation-of-children-in-gaza-on-the-brink-of-a-mental-health-crisis-new-research-shows/

2. Al Jazeera. Save the children: Gaza children on brink of mental health crisis. June 4, 2018. Accessed March 26, 2024. https://www.aljazeera.com/news/2018/06/save-children-gaza-children-brink-mental-health-crisis-180603190059320.html

3. Trapped: the impact of 15 years of blockade on the mental health of Gaza’s children. Save the Children. 2022. Accessed March 26, 2024.

6. Thabet AM, Thabet SS. Trauma, PTSD, anxiety, and resilience in Palestinian children in the Gaza Strip. British Journal of Education, Society & Behavioural Science. 2015;11(1):1-13.

7. Children’s lives threatened by rising malnutrition in the Gaza Strip. World Food Programme. February 19, 2024. Accessed March 26, 2024. https://www.wfp.org/news/childrens-lives-threatened-rising-malnutrition-gaza-strip

8. Farajallah I. Continuous traumatic stress in Palestine: the psychological effects of the occupation and chronic warfare on Palestinian children.  World Social Psychiatry. 2022;4(2):112-120.

9. Farajallah, I. The unseen damage to Palestinian children by the Israeli occupation. March 7, 2024. Accessed March 26, 2024. https://www.trtworld.com/magazine/the-unseen-damage-to-palestinian-children-by-the-israeli-occupation-17268417