The Impact of Political Violence on Young Children in Israel

The Impact of Political Violence on Young Children in Israel Final Report for the Bernard van Leer Foundation July 2012

Ruth Pat-Horenczyk, Ph.D.1,2* Yuval Ziv, M.A.1 Michal Achituv, M.A.1 Naomi Baum, Ph.D.1 Danny Brom, Ph.D.1,2 1

Israel Center for the Treatment of Psychotrauma

Miriam Schiff, Ph.D.2* Rana Eseed.2

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Paul Baerwald School of Social Work and Social Welfare, Hebrew University

Acknowledgements: The data was collected by the B. I. and Lucille Cohen Institute for Public Opinion Research at Tel Aviv University. We would like to thank Dr. Anat Oren and Ms. Mazal Dudu-Ha'Levi from the Lucille Cohen Institute for their excellent work on the data collection. We are very grateful to Aden Ratner-Stauber for the careful editing of this report. * Equal contribution by the two principal investigators: Ruth Pat-Horenczyk and Miriam Schiff

‫) ע " ש תמי ואלברט לטנר‬760284085 .‫ר‬.‫ הרצוג המרכז הישראלי לטיפול בפסיכוטראומה (ע‬ 53007 ‫ ירושלים‬, 0500 .‫ד‬. ‫ ת‬,75 ‫רח ' שמריהו לוין‬ The Temmy and Albert Latner Psychotrauma Center  59 Shmariahu Levin St., P.O.B. 3900, Jerusalem 91035 [email protected]  04-8225888 : ' ‫ טל‬Tel:  04-8225555 : ‫ פקס‬Fax:  www.traumaweb.org

THE IMPACT OF POLITICAL VIOLENCE ON YOUNG CHILDREN IN ISRAEL

Executive summary The purpose of this study was to assess the impact of exposure to political violence and other traumatic events on young children (ages 2 to 6 years old) and their mothers, based on a representative sample of 904 Arab and Jewish mothers in Israel. The study focused on behavioral and developmental problems and symptoms of Post Traumatic Stress Disorder (PTSD) in young children, and the post traumatic distress and available support and resources for the mothers. Based on recent developments in the field of childhood trauma and the growing interest in identifying maternal protective factors, we utilized innovative measures of maternal emotional regulation to investigate the parental capacity to mitigate distress of young children coping with trauma. Special emphasis has been made on the impact of ethnicity (Arab and Jewish), socioeconomic status of the families, religion, and immigration. Since the relationship with the primary caregiver is paramount to understanding the child’s ability to adjust in the aftermath of traumatic events, this study focused on the role of the mother in either exacerbating or mitigating the child’s distress and behavioral symptoms. We examined a broad range of developmental, behavioral and emotional difficulties young children experience, as well as the impact of maternal distress, maternal emotional regulation, and the availability of social support and social services to alleviate the posttraumatic distress of young children. Main Results:  More than half of the mothers and more than 10% of their children (under 6 years old) were exposed to an event of political violence.  One third of the mothers and their children experienced traumatic events unrelated to the political violence.  6.7% of the children who were exposed to traumatic experiences manifested symptoms of PTSD. 9.5% of the children in the sample suffered from internalizing symptoms, and 3.5% from externalizing symptoms.  Among the mothers who were exposed to trauma 13.3% suffered from symptoms of full or partial PTSD and 25.5% suffered from depression.  Arab mothers were the most vulnerable population. They reported greater exposure to events of political violence than Jewish mothers. The prevalence of likelihood for PTSD in Arab mothers is three times greater than the prevalence of the PTSD in Jewish mothers. Arab mothers also reported greater difficulties in emotional regulation, lower levels of flexibility, more mother-child rejection, lower levels of social support and less availability of services than Jewish mothers.  Mothers from low income families were the next vulnerable population. They reported higher levels of Post Traumatic Symptoms (PTS) and greater likelihood for PTSD, greater difficulties in emotional regulation, more mother-child rejection, lower levels of social support and less availability of educational and recreational services, than mothers from higher income families.  The third (in descending order) vulnerable group was immigrant mothers. Compared to Israeli born mothers, immigrant mothers reported lower levels of social support and not benefitting from the greater availability of educational and recreational services.  Ultra-religious mothers were found not to be vulnerable to psychological distress or child's difficulties.

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THE IMPACT OF POLITICAL VIOLENCE ON YOUNG CHILDREN IN ISRAEL 

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In parallel, Arab children were the most vulnerable population among the child population. The second vulnerable group was children from low income families. We found no indication of vulnerability due to immigration or religiosity. In general, the traumatic experiences of the child, the maternal internal capacity (i.e., self regulation), and the quality of the mother-child relationship (i.e., the lack of maternal rejection), had a greater impact on the child than the political violence. Children's psychological and behavioral distress can be attributed to three factors: (1) societal ecological disadvantages: Arab ethnicity, low income, lack of services or lack of awareness to the advantages of service utilization; (2) child's own negative experiences: trauma history (3) mother's lack of internal resources, dyadic capabilities (child's acceptance), and external resources (lack of social support). As for mothers' internal resources- mothers' low emotional regulation capabilities are major risk factors for children's emotional and behavioral symptoms including: internalizing problems, externalizing problems, aggression and total behavioral and emotional symptoms. Study Implications:

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There is a need to develop more psychosocial services that can mitigate the impact of trauma on young children. Extra services are needed for low income families and Arab families in need. There is a need to tailor culture specific services for the Arab and Jewish population according to their different needs. The strong influence of mother's emotional regulation on her child's distress calls for the development of parental programs that focus on strengthening the parental emotional regulation ability and encourage parents to seek support when in need. Our results point to the importance of maternal internal and external resources. Therefore, interventions for parents of young children in the context of trauma should not be limited to the treatment of maternal distress. Interventions should also focus on strengthening protective factors, such as mother's emotional regulation ability, social support and the advancement of community services. Our results indicate that attention problems were predicted by child’s background, recent traumatic experiences and mothers’ resilience factors. Based on evidence linking attention problems to later development of aggressive behavior, prevention programs should include a special emphasis on the role of trauma and maternal resiliency in the development of attention and aggressive problems and should be implemented as early as possible. This study demonstrates the feasibility of identifying distress in early childhood and emphasizes the necessity of using developmentally appropriate measures to detect distress in young children. Further longitudinal research is recommended to get a deeper understanding of the effects of trauma on child development, and the mitigating effects of parental care on how children develop in the wake of trauma. Further longitudinal research should have the young children in this study answer the questionnaires themselves as they get older, as what parents report about their children may not be consistent with what children report about themselves.

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The Impact of Political Violence on Young Children in Israel Children's experiences are a function of the contexts in which they live. Violent and aggressive behavior in Israel has been recognized as a significant societal concern (Israel Sderot Conference on Social Issues, November, 2010). Moreover, recent research has emphasized the positive correlation between exposure to political violence and the resulting post traumatic distress, as well as a variety of behavioral and emotional problems, including aggressive behavior among school children and adolescents. (Pat-Horenczyk, Peled, Daie, Abramovitz, Brom, Chemtob, 2007). Data suggest that violent behavior manifested in adolescence often originates in early childhood, which would mean that unprocessed trauma induced by exposure to violence increases the probability of later psychopathology and aggressive behavior. Research has found that violence exposure can lead to both emotional constriction and desensitization to violence in a subset of exposed youth, increasing the risk of subsequent perpetration of aggressive behaviors as a problem-solving, self-protective, or retaliatory strategy (Farrell & Bruce, 1997). Ozkel et al. (2011) explored the pathways from violence exposure to aggressive behaviors in urban, fourth-grade elementary school youth and found that almost all (98.8%) of the participants reported experiencing at least one lifetime violent event and more than half reported direct personal victimization. Both Posttraumatic stress symptoms and permissive attitudes toward violence mediated the relationship between exposure to violence and acting out aggression. Children exposed to violence at a young age who developed Post Traumatic Symptoms (PTS) or had permissive attitudes towards violence were more likely to exhibit aggressive behavior in the 4th grade. Therefore, Ozkel et al (2011) suggests that intervention at a very young age is essential as there is an early onset of violence exposure in children, and aggressive behavior that develops must be prevented. In the context of political violence, Laor and his colleagues (1997, 2001) demonstrated that posttraumatic symptoms such as avoidance and hyper-arousal were documented in Israeli 3


pre-school children after the first Gulf war. Another Israeli study (Wang et al., 2006) investigated the reactions of children ages 2-4 who were exposure to terrorist attacks during the second Intifada, and distinguished the different kinds of exposure to traumatic events. They found that toddlers who were directly exposed to terrorist attacks, as compared to those who were indirectly exposed, expressed more emotional and behavioral problems such as internalizing (e.g., withdrawal) and externalizing (e.g., aggressive behaviors) problems and anxiety symptoms. Additionally, it is important to consider the allostatic load hypothesis (Danese & McEwen, 2011), which states that it is not the childhood adversity per se that is the cause of PTSD and other psychological and behavioral distress, but the cumulative effect of exposure to war and the additive effect of all other traumatic events experienced in the past or present (Kira et al., 2011).This implies that aside from war, other severe forms of childhood adversity as well as lack of adequate buffering, result in allostatic load which may lead to a profound functional impairment associated with harmful consequences on health throughout the life-course (Danese & McEwen, 2011). Thus exposure to trauma can negatively manifest itself in children emotionally, behaviorally, and physiologically. Although children with direct exposure to terrorist attacks are more likely to develop emotional and behavioral problems, the support of a caregiver can greatly mitigate these symptoms. Traumatic experiences shatter the "protective shield" (Freud, 1920) of young children who instinctively rely on their caregivers for protection from danger (Bowlby, 1969). Attachment to parents can be a major protective factor for the child throughout his or her development. Parents have the capacity to provide a sense of safety and security, help the child process his experiences, be attuned to the child’s needs and feelings, assist the child to effectively regulate his or her own emotions, and provide a model for adaptive coping for the child. While parents have the capacity for moderating traumatic events in the child’s life, their own distress may affect the child’s distress more than the objective traumatic events

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themselves. It has been consistently shown that parental depression is positively correlated with symptoms of Post-Traumatic Stress Disorder (PTSD) in their children. Scheeringa & Zeanah (2001) proposed the concept of Relational PTSD which refers to the co-occurrence of PTSD simultaneously in parent and child, when the symptomatology of one partner (usually the adult) exacerbates the symptomatology of the other (child). A related term is “transgenerational” referring to the process of transmission of PTSD in the parent to the child. There is strong scientific evidence that children’s mental health in the first 5 years of life can be profoundly affected by the impact of traumatic stressors such as domestic violence, child abuse, community violence, and war, which creates a long lasting effect (Chu & Lieberman, 2010). A child’s resilience under these conditions is predicted by maternal wellbeing, quality of care giving, and environmental supports, which can lessen the impact of trauma and prevent the onset of behavioral problems and pathological symptoms in the future (ibid, 2010). Additionally, Feldman and Vengroberg (2011) found that mothers of warexposed children with PTSD were less educated and had less family support than mothers of children without PTSD. Maternal proximity to the traumatic event—but not the child’s proximity—differentiated between children with and without PTSD. Thus the mother’s exposure to trauma and her support system can directly affect their children. Alicia Lieberman, a leading expert in the field of childhood trauma, found that mothers of children with PTSD were less sensitively and consistently responsive to their children’s signals of distress during evocation of the mother’s trauma, perhaps because they were more actively triggered by the memory of the traumatic event which impaired their ability to attend to their children (Lieberman, 2011). This strengthens the argument that mothers experiencing PTSD or other difficult circumstances can exacerbate the development of PTSD in their children.

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This study investigated the differences between Arab and Jewish Israeli young children exposed to trauma. It has been shown that early childhood events greatly affect future emotional and behavioral wellbeing. In a study which focused on school children Schiff et al. (2012) found that adolescents who experienced childhood abuse or other traumatic events, also experienced greater levels of PTS, substance use, and violence perpetration. They also found that Arab students reported higher levels of posttraumatic symptoms than their Jewish peers, despite experiencing lower war exposure compared to Jewish adolescents in their area. Although there has been research on Jewish and Arab Israeli adolescents’ exposure to war and violence and developing negative behaviors, little is known about the impact of political violence and other types of trauma on the distress and development of very young children. Our current study, based on a representative sample of the Israeli population, fills this gap in the literature and examines the impact of political violence and other types of trauma on both Arab and Jewish young children (ages 2 to 6 years old) and their mothers. This study also takes into account the socioeconomic status of mothers and their children. Since the relationship with the primary caregiver is paramount to understanding the child’s ability to adjust in the aftermath of a traumatic event, the study focuses on the role of the mother in either exacerbating or mitigating the child’s distress and aggressive behavior. We examine a broad range of developmental, behavioral and emotional difficulties young children experience, as well as the impact of maternal distress, maternal emotional regulation, and the availability of social support and social services to alleviate the posttraumatic distress of young children. The results of this study can be used to facilitate the development of evidenced-informed and more targeted prevention and intervention strategies for young children and mothers exposed to trauma and political violence.

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Method Sample The study sample was recruited as a representative sample of Israeli citizen based on the Ministry of Interior sampling frame which is the most accurate and updated sampling frame that exists. The total sample consisted of 904 mothers, with ages ranging from 16 – 53 (M = 34.08; SD = 5.76), and their children ranging from 23 to 80 months (n=904, M= 46.6 months, SD= 13.78), 53% of the sample were boys. 91% of the mothers reported that they were married. The median number of children was three (for both Arab and Jewish mothers alike). Almost a quarter of the sample was Arabs (22.5 %). Of the 701 Jewish mothers 75.6% were born in Israel while 24.4% immigrated from a range of countries. The majority of the Jewish sample was secular (43.4%) or traditional non-religious (additional 19.7%). Among the Arab sample 46.7% reported being religious, 17.9% reported being traditional non-religious, and 19.6% were secular. From the total sample 16.5% were defined as low income families (income below or equal to 4500 NIS per month, based on categorization of the Israel Bureau of Statistics). 38.5% of the Arab families and 10.6% of the Jewish families were classified as low income families. Procedure Sample recruitment and structured face-to-face interviewing of the mothers was conducted by the Lucille Cohen Institute for Public Opinion Research at Tel-Aviv University, a university public opinion center that combines theory and methodology development with public opinion surveys conducted with high academic standards. Mothers were recruited from statistical areas that were proportionally sampled from defined geographical and socioeconomic strata. Strata were defined by ethnicity (Jewish/Arabs), geographical area (Haifa and North Israel, Ashdod and south Israel, and all other areas in Israel), religiosity and socioeconomic level. We oversampled areas with higher exposure to political violence (from

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south and north Israel) and then used weights to make sure that data on the total population will be representative. The statistical areas were based on the most updated data provided by the Israel Statistics Bureau 2009 census. If only one child ages 2 to 6 lived in the sampled household, then he/she would be the "study child", meaning that all questions in the structured questionnaire were referring to him/her. If the household included more than one child ages 2 to 6 then the interviewer asked for the birth dates of all those children. The "study child" was randomly chosen based on whose birthday was the most recent. Interviews were conducted in Hebrew for the Jewish mothers and Arabic for Arab mothers. We approached 1280 household in order to achieve 904 complete interviews. Thus, despite the length of the questionnaire (more than 25 pages) and the research population of mothers leading busy lives, we managed to achieve a 70.6% response rate. Measures Demographic information A short questionnaire especially designed for this study included 14 items regarding demographic background (age, education, place of birth, religion, working status, marital status) and socio-economic status (number of rooms, level of family income, number of people living in the house). All questionnaires were translated and cross translated to Hebrew and Arabic

Child's exposure to trauma, functioning & psychopathology (mother's report) Exposure to Political Violence Mother's report on child exposure to political violence was based on the Israeli Trauma Exposure Questionnaire (Pat-Horenczyk, Chemtob, Abramovitz, Baum, Daie, & Brom, 2002). The 6 items of the questionnaire represent various forms of exposure to political violence, which includes terrorist attacks, missile attacks, or war. Participants were asked

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whether the child was exposed at all, once or more than once to missile attacks and other forms of political violence. This questionnaire was frequently used in previous research (PatHorenczyk et al., in press). Child's Trauma History (TESI-P) Mother's report on child exposure to traumatic events was measured by the Traumatic Events Screening Inventory, a 12 item questionnaire representing a wide range of potentially traumatic events including accidents, hospitalizations, physical or sexual abuse, natural disasters, community violence, witnessing domestic violence, and interpersonal losses due to severe illness or injury during their lifetime. This questionnaire was widely used in previous studies. The 2-4 month test-retest reliability of the TESI-P ranged from .50 to .70, and parentchild agreement kappas on TESI-C versus TESI-P items ranged from .64 to .79 (Ford et al., 1999; Ford & Rogers, 1997). Exposure to media A short questionnaire especially designed for this study includes 4 items measuring exposure to general television and radio on a regular day, exposure to news broadcasted via television and radio on a regular day, exposure to computers on a regular day, and exposure to news broadcasted during a security risk or terrorists attack. It was evaluated on a Likert scale of 0-4: no exposure at all (0), up to one hour of exposure a day (1), 1-2 hours of exposure a day (2), 2-3 hours of exposure a day (3), and more than 3 hours of exposure a day (4). Post traumatic Symptoms This questionnaire was adapted from a clinical interview version of the mother. The original clinical interview was designed to assess Post Traumatic Stress Disorder in preschool children (Scheeringa, Zeanah, Myers, & Putnam, 2003). The questionnaire is comprised of 25 questions focusing on observed symptoms and behavior instead of subjective experience. The questionnaire is composed of six clusters of items instead of the 5 listed in

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the DSM IV. The additional cluster of symptoms relates to developmental changes such as developmental regression, separation anxiety etc. Each item is rated on a 3-point scale (0= no, 1=sometimes, 2 = yes). The questionnaire provides a preliminary determination of the DSMIV PTSD diagnostic status, a count of the number of symptoms endorsed, a rating of symptom severity, and a rating of the level of impairment of functioning. This study used the Hebrew version of the interview (Cohen & Gadassi, 2009). In the clinical interview items are scored by a clinical interviewer using clinical judgment based on parents answers and examples. In the current research, the interviewers were not clinicians, and therefore were directed to score this interview based on the report of the parents instead of the interviewer's clinical impression. Developmental and Behavioral Problems Maternal rating of children's behavioral/emotional problems was assessed using the Child Behavior Checklist (CBCL) for children 1.5 to 6 years of age (Achenbach, 1991). The forms obtain parents’ ratings of 0 to 2 (0=not at all, 1=sometimes, 2 = yes) of 99 problem items, plus descriptions of problems, disabilities, what concerns parents most about the child, and the best things about the child. Standardized scores (T-scores) are produced for seven Syndrome scales - Withdrawn, Somatic Complaints, Anxious/Depressed, Emotional reactivity, Sleep Problems, Attention Problems, and Aggressive Behavior, and for three Total scales Internalizing, Externalizing and Total Problem scale. The scores indicate the child's relative status on the basis of a normative sample of non-clinical children population. For each of the three total scales a T-score under 60 is in the normal range, a T-score between 60-63 is considered borderline and a T-score above 63 is in the clinical range. As for the other seven scales, a T-score under 65 are in the normal range, a T-score between 65-67 is considered borderline and a T-score above 67 is in the clinical range. This measure has been standardized on large samples of children in the US and Israel. Test-retest reliability (in an 8-day interval)

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for the total score was r = .90, and for the different scales ranged from r = .68 to r = .92 (with the mean r of .85) indicating good test-retest reliability (Achenbach & Rescorla, 2001) Emotional regulation Mothers completed a shortened version of Larsen and Diener's (1987) Affective Intensity Scale (Eisenberg et al., 1993), a 10-item scale assessing the intensity with which children experience positive and negative emotions such as happiness, anxiety, anger, and upset. Each item is rated on a 7-point scale (1 = never, 7 = always). Example items include, "When my child feels an emotion, either positive or negative, he/she feels it strongly" and "Even when happy, sad, or upset, my child does not get highly emotional." Higher scores indicate greater emotional intensity and emotional intensity has been found to be negatively related to preschoolers' social skills and peer status (Eisenberg et al., 1993). Mothers' Exposure to Trauma and Psychological Distress Exposure to Missile Attacks The Israeli Trauma Exposure Questionnaire (Pat-Horenczyk, Chemtob, Abramovitz, Baum, Daie, & Brom, 2002) was adapted for mothers using the same categories of exposure to missile attacks, as in the child's exposure questionnaire (see above). Post Traumatic Stress Symptoms Maternal self-report of exposure to traumatic events, post-traumatic symptoms and functional impairment was assessed using the Posttraumatic Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997). The PDS is a 49-item self-report measure that yields a preliminary determination of DSM-IV PTSD diagnostic status, a count of the number of symptoms endorsed, a rating of symptom severity, and a rating of the level of impairment of functioning. Example items include: "Having bad dreams or nightmares about the traumatic event" and "Feeling irritable or having fits of anger". Each item is rated on a 4-point scale (0 = Not at all or only one time in the past month, 3 = 5 or more times a week in the past month

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/almost always). A previous study reported high internal reliability of .85 Cronbach’s alpha. The concurrent validity with the PTSD scale of the SCID (Structured Clinical Interview for DSM-III) clinical interview was r = .94. (Foa, Riggs, Dancu & Rothbaum, 1993.) Maternal Depression Mother's self-report of depression was assessed using The Center for Epidemiological Studies Depression Scale (CES-D) (Radloff, 1977). The CES-D is a 20-item self-report scale that measures symptoms of depression in non-clinical populations. The responses are summed to a total score, which can range from 0 to 60, with a score of 16 or higher considered to have clinical significance. A score between 26 and 30 is considered as moderate depression and a score of 31 or higher is considered as severe depression. Example items include: "I felt lonely" and "My sleep was restless". Each item is rated on a 4-point scale (0 = Rarely or None of the Time (Less than 1 Day) during the past week, 3 = Most or All of the Time (5-7 Days) during the past week). Radloff (1977) reported internal consistency reliability of .90 Cronbach’s alpha and Test-Retest reliability after 4 weeks of r = .67. Stressful Events and Emotional Reaction during Pregnancy A short questionnaire designed for this study included six items regarding stressful events during the mother's last pregnancy and the pregnancy of the child in the research study (pregnancy complications, exposure to stressful events during pregnancy, and decreased mood following pregnancy). Major Risk and Protective Factors Mothers' Emotional Regulation The Difficulties in the Emotion Regulation Scale (DERS; Gratz and Roemer, 2004) is a 36-item self-report questionnaire designed to assess multiple aspects of emotional dysregulation. Participants are asked to rate statements regarding their emotional states and reactions in times of distress. Each item is reported on a 5-point scale (1 = almost never, 5 =

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almost always). Example items include: "I have no idea how I am feeling" and "When I’m upset, I feel out of control". This measure yields a total score as well as scores on six scales: (1) Non acceptance of emotional responses (2) Difficulties engaging in goal directed behavior (3) Impulse control difficulties (4) Lack of emotional awareness (5) Limited access to emotion regulation strategies and (6) Lack of emotional clarity. Cronbach’s alpha was calculated to determine the internal consistency of the DERS items. The DERS had high internal consistency with Cronbach’s alpha of .93. Item-total correlations ranged from r = .16 to r = .69. Thirty-four of the items had item total correlations above r = .30. All of the DERS subscales (computed from the 6 factors obtained in the factor analysis) also had adequate internal consistency, with Cronbach’s alpha ranging form .80 to .89 for each subscale (Gratz and Roemer, 2004). Flexibility The PACT scale (Perceived Ability to Cope with Trauma; Bonanno, Pat-Horenczyk, & Noll, 2011) is designed to measure people's evaluation of their ability to cope with trauma. The scale includes 20 items that focus on two aspects of coping with trauma: Trauma focus (8 items) and Forward focus (12 items). Participants are asked to report to what degree they would be able to use different kinds of behaviors and strategies in the weeks following a potentially traumatic event. Each item is reported on a 7-point scale (1 = not at all able; 7 = extremely able). The Trauma focus aspect includes behaviors such as: "Pay attention to the distressing feelings that result from the event" and "Face the grim reality head on", whereas the Forward focus aspect includes behaviors such as: "Stay focused on my current goals and plans" and "Look for a silver lining". Scores are obtained for the two aspects as well as a total flexibility score. Internal consistency reliability of the forward focus scale was alpha Cronbach’s = .85 and of the trauma focus scale alpha Cronbach’s = .79. The structural,

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convergent, discriminant, cross cultural validity of the questionnaire was also supported. (Bonanno et al., 2011). Parental Acceptance, Rejection and Control The short version of the Parental Acceptance and Rejection/control Questionnaire (PARQ-Control; Rohner & Khaleque, 2005) is designed to assess four domains of parental functioning: (1) warmth/affection; (2) hostility/ aggression; (3) indifference/neglect; (4) undifferentiated rejection. The scale consists of 24 items which are reported on a 4-point scale (1= almost never true; 4= almost always true). Example items include: "I pay no attention to my child" and "I let my child know I love him/her ". The mean unweighted alpha coefficient of the parents version of the PARQ was .84 in Meta-Analyses conducted by Rohner (ohner & Khaleque, 2005). The reliability of the control scale was also supported with an alpha coefficient of .69. The reliability of the short version of the parents PARQ/control questionnaire is not yet published. Social Support Survey The Social Support Survey is a self-report measure of social support. The scale includes 20 items that focus on four functional support scales: emotional/informational, tangible, affectionate and positive social interaction, and also yields an overall social support index. Each item is reported on a 5-point scale (1 = none of the time; 5 = all of the time). Cronbach’s alpha reliability scores ranged from .91 to .96 for the four scales, and was .97 for the total score (Sherbourne & Stewart, 1991).

Availability and Utilization of Health and Community services A questionnaire designed for this study includes 40 items regarding several domains of the utilization of community, health, and psycho-social services. Mothers were requested to report about several health issues regarding themselves and their child (general health,

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smoking and drinking habits), the availability of health and community services (Is there a school, play ground, community center etc. near your home?) and their utilization of such services (Does your child go to school, play ground, community center etc.? Did you go to the family doctor, mental health clinic, police, welfare services etc.).

Main Results Trauma Exposure More than half (57.4%) of the mothers were exposed to at least one traumatic event. Almost half of the mothers (47.8%) were exposed to at least one act of political violence, such as hearing the falling of rockets. One third (34.3%) of the mothers experienced at least one traumatic event other than political violence, such as domestic violence or car accidents. 37.8% of the children were exposed to at least one traumatic event. 13% of the children were exposed to at least one act of political violence, and one third of the children (31.9%) experienced at least one type of traumatic event other than political violence. Risk Factors for Exposure to Traumatic Events: Ethnicity Arab mothers reported greater exposure to political violence (66.8% compared to 42.9% of Jewish mothers). Jewish mothers reported greater exposure of their child to political violence (14.7% and. 6.4% respectively) and trauma history (37.6% and. 9.7% for Jewish and Arab children, respectively). Maternal Distress Symptoms of full PTSD were reported by 4% of the mothers and an additional 3.8% reported partial PTSD. Among mothers who experienced at least one traumatic event, 7% reported full PTSD and an additional 6.3% reported partial PTSD. One quarter of the mothers (25.5%) reported depressive symptoms in the clinical range (score >16).

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Risk Factors for Maternal Distress Ethnicity The rate of full PTSD was found to be 8.7% and 2.7%, among Arab and Jewish mothers respectively. Depressive symptoms within the clinical range were reported by 37.5% of the Arab mothers and 20.7% of the Jewish mothers. Low family income The rate of full PTSD was significantly higher among low income families than among families with higher income (8% and 3.7% among respectively) and this was true for depressive symptoms within the clinical range as well (32% in mothers from low income families and 22.9% in the higher income mothers). Child Behavioral and Emotional Problems Among children exposed to traumatic events, 2.4% were identified with full PTSD (according to the maternal report) and additional 4.3% showed symptoms of partial PTSD. Almost 10% (9.5%) of the children were identified within the borderline to clinical range of internalizing behavioral problems and 3.5% of the children were in the borderline to clinical range of externalizing behavioral problems. Attention problems within the borderline to clinical range were reported for 1.8% of the children. About 1% (0.9%) of the children were identified within the borderline to clinical range of aggressive symptoms and several symptoms were reported in rates demanding attention, such as defiant behavior (44.3%), destroys things belonging to his family or other children; disobedient (43.0%), sullen or irritable (36.26%), hits others (17.4%) and gets in many fights (16.0%). Risk Factors for Child Behavioral Difficulties based on CBCL scales: Ethnicity Arab children had significantly higher levels of all behavioral problems examined, as compared to Jewish children, including: aggressive behavior (1.2% vs. 0.9%), attention

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problems (6% vs. 0.7%), externalizing behavioral problems (8.9% vs. 2.3%) and internalizing behavioral problems (13.1% vs. 8.7%). Low Family Income Children from low income families had significantly higher levels of all behavioral and emotional problems. Utilization of Services by Mothers The mothers were asked to report on the availability and utilization of educational and recreational services in their neighborhood as well as on the utilization of helping services aimed at providing psycho-social, physical or spiritual support (counseling, family doctor, child's teacher, rabbi or other religious authority, mental health service, crisis services, etc). Educational Services Most mothers reported their children attending kindergarten (93%), almost 60% (58.7%) participate in informal education, and one quarter (24.1%) of the children attend afternoon complimentary education services. Recreational Services More than 80% (82.2%) of the children go to playgrounds. 23.7% of the children or mothers attend activities in the community center. Helping Services 14% of mothers went to counseling (individual, couple or family), 13.4% consulted with a school psychologist, and 13.2% met with a rabbi or other religious leader. 7.5% went to a welfare agency and 43% of mothers reached out for help to their child's teacher or to their family doctor. Ethnicity Arab mothers reported less availability of both educational and recreational services, as compared to Jewish mothers (average of 1.98 vs. 3.26 for educational and 0.85 vs. 2.35 for

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recreational facilities). Arab mothers did not differ from Jewish mothers in utilization of recreational services (averages of 2.0 vs. 2.03); however, they reported less utilization of educational services (averages of 1.1 vs. 1.75) and less utilization of helping services (average of 0.93 vs. 1.56). For example, 34.5% of Arab mothers compared to 44.7% of Jewish mothers consulted with their family doctor while 29.3% and 46.3% of Arab and Jewish mothers respectively consulted with their child's teacher. Risk and Protective Factors for Child Behavioral and Emotional Difficulties Aggression We found that Arab ethnicity, male gender, and not being hospitalized in the past 12 months are significant child's predictors of child's aggressive symptoms. Mother's difficulties in emotional regulation were the only significant mothers' predictors of child's aggressive symptoms. Attention problems Arab ethnicity, male gender, not being hospitalized in the past 12 months and, attendance in recreational services but less availability of recreational services are all significant child's predictors of child's attention problems. Mothers' with fewer depressive symptoms, and lower levels of perceived social support are significant mothers' predictors of child's attention problems. Internalizing problems Child's trauma history, lack of attendance in educational settings, Arab ethnicity, and male gender are significant child's predictors of child's internalizing behavior. Immigrant mother, mother's lack of acceptance of her child, and mother's difficulties in emotional regulation are significant mother's predictors of child's internalizing symptoms.

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Externalizing Problems Child's trauma history, not being hospitalized in the past 12 months (yes/no), Arab ethnicity, male gender, lack of attendance in educational settings and more attendance in recreational services, are significant child's predictors of child's externalizing behavior. Mother giving birth in the past 12 months, less depressive symptoms, difficulties in emotional regulation, lower levels of flexibility, and less perceived social support are all significant mothers' predictors of child's externalizing symptoms. Total behavioral and emotional symptoms We found that Arab ethnicity, male gender, child's exposure to political violence, child's trauma history, lack of attendance in educational settings and more attendance in recreational services, are all significant child's predictors of child's behavioral and emotional symptoms. Being an immigrant mother, giving birth in the past 12 months, mother's lack of acceptance of her child, and mother's difficulties in emotional regulation are significant mothers' predictors of child's behavioral and emotional symptoms. The extent of mother's seeking helping services is also a significant predictor (correlate) of child's behavioral and emotional symptoms. Utilization of Services and Child Distress Regression analyses included the utilization of educational, recreational and helping services. We found that utilization of helping services was positively associated with the child’s distress among the Jewish population, while utilization of recreational services was positively associated with child’s distress among the Arab population. While at first glance this looks puzzling, the reasonable interpretation is that mothers who feel their child is in distress apply for services. Jewish mothers seek help in the services that offer professional help while Arab mothers prefer seeking help in more normative, less stigmatized services such as recreational services (see the implication paragraph for further discussion).

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Summary and Implications This study, based on a representative sample of the Israeli population, points to the high level of exposure of young children to trauma. More than one third of the children below the age of 6 were exposed to trauma. Exposure to prior trauma (not related to political violence) had a major impact on the child's current distress and on all behavioral and emotional symptoms assessed. Of the children who were exposed to any type of traumatic experience 6.7% manifested symptoms of full or partial PTSD. 9.5% of the children in the sample suffered from internalizing symptoms, and 3.5% from externalizing symptoms. Among the mothers who were exposed to trauma 13.3% suffered from symptoms of full or partial PTSD and 25.5% suffered from depression. There is growing scientific evidence that early trauma exposure, as well as maternal distress and relational PTSD, may create a significant risk for future adaptations of young children. A central finding of this study is that both mothers and children in the Arab sector of Israeli society reported higher levels of distress. Thus the Arab population is one of the most vulnerable populations in Israel. Other vulnerable populations are families with low income. Additionally, mothers who gave birth in the last year were more vulnerable to higher levels of distress. These findings have implications to facilitate the development of services for these vulnerable populations. Our study was not limited to the assessment of maternal and child distress, but also focused on the role of maternal internal and external resources. The results show that maternal ability for emotional regulation is indeed a protective factor that can buffer the child’s distress. We found that maternal difficulties in emotional regulation were strong and consistent predictors of child distress. Additionally, maternal rejection, lack of social support, and maternal depression contributed to various aspects of the child’s distress. In general, the traumatic experiences of the children, the maternal internal capacity (i.e., self-regulation) and

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the quality of the mother-child relationship (i.e., the lack of maternal rejection), had a greater impact on the child than the political reality. The Implications of the Findings: (1). Need for Services: The findings of this study show there is a need to develop more psychosocial services that can mitigate the impact of trauma on young children. The child is dependent upon the mother and the mother, on her part, is influenced by the availability of social support and psychosocial services. Interventions for young children and parents should take this integrative ecological perspective into consideration. In addition, extra services are needed for low income families. The study also indicates the need to tailor culture specific services for the Arab and Jewish population according to the different needs. Therefore, the accessibility of services in the Arab population may need special attention. For example, the accessibility of recreational or domestic violence services may need to be increased in Arab populations, as their vulnerability to psychological distress may be due to lack of these needed services. There is also a need to train professionals to actively reach out to families whose children experienced prior trauma, families with sick children, mothers after giving birth (especially among the Arab population), and mothers from low income families. (2). Need for program development: The centrality of parental skills for secure child development is apparent for all families. The important finding regarding the strong influence of maternal emotional regulation to mitigate her child's distress, calls for the development of programs for parents to enhance their capacity for emotional regulation. These programs should focus on providing psychoeducation and enhancing coping strategies including those of seeking support. For example, evidence-based effective dyadic interventions for parents and young children (see: Van Horn & Lieberman, 2009) can be implemented with special emphasis on the mother's ability to

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regulate her emotions, on improving parental acceptance of the child, on coping with trauma and on building resilience in young children. Programs for parents should address coping with a broad range of behavioral and emotional difficulties of young children, including attention problems and aggressive behaviors. There is evidence for the link between attention problems and later development of aggressive behavior, and prevention programs should therefore start addressing this issue as early as possible. Our findings are also consistent with prior research showing that maternal well-being affects the quality of care giving and both factors may independently or in conjunction protect or compound the negative impact of traumatic events on the child (Chu & Lieberman, 2010, Feldman and Vengrober, 2011). In addition to maternal well-being and quality of care giving, support networks also serve as a resilience factor for young children and should be the focus of intervention for families of war-exposed infants and children (Feldman & Vengrober, 2011). Lieberman (2011) further emphasizes the importance of relational based interventions focusing simultaneously on both the child’s and mother’s emotional regulation abilities and the mother’s ability to understand and respond sensitively and in developmentally appropriate ways to the child’s fears and attachment needs, “A child’s resilience does not exist in a vacuum but is buttressed by emotionally available care-giving relationships" (Lieberman, 2011). (3). Need for early detection, prevention and intervention: This study shows the feasibility of identifying distress in young children. Detection of distress in early childhood has a tremendous potential for preventing developmental problems in later childhood. The results substantiate the importance of using developmentally appropriate measures for identifying post traumatic distress in young children. Current literature on trauma in children and adults stress the centrality of early childhood trauma in the development of psychopathology. There is growing scientific evidence that

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early childhood trauma can have profound and long lasting impact on development and adjustment (Chu, Lieberman, 2010). The relationships we found in our study stress the importance of early trauma, but also show that early identification is a real possibility. The next challenge is to develop and implement systemic screening procedures for exposure to trauma and posttraumatic related distress in both young children and their parents, so that they can be referred to prevention or interventions programs. (4). Need for further research: Our study suggests that exposure to political violence and other trauma has a deleterious effect on the development of young children. The findings in the current study are consistent with the accumulating evidence showing the importance of the mother as a major protective factor for optimal child development. However, this study is cross sectional, which provides a snapshot picture of the children, their distress, their mothers’ distress, and the relationship between mother and child. This one-time assessment has given us directions and hypotheses, but cannot answer the question of the long-term consequences of early trauma. In order to get a deeper understanding of the effects of trauma on the development of children, children must be followed longitudinally. Longitudinal research can also give insight into the mitigating effects of parental care on how children develop in the wake of trauma and how their world views are being influenced. There is a dearth of studies looking at healthy trajectories, as well as at the way children adapt to living in a post-war or post-disaster reality and what can help minimize the damage that trauma inflicts. As indicated by Feldman and Vengrover (2011), future research must detail the effects of continuous war, terror, and armed conflict on young children's mental health, behavior regulation, and developmental trajectories. The results of this study can be used as a baseline for repeated assessments of various aspects of children's development and for monitoring the changes in children's distress or resilience due to new programs and interventions. Additional qualitative research, which will

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focus on the needs and obstacles for utilization of services, can be useful for the development of culturally sensitive and effective psychosocial services. Future research can also take the child’s gender into account as studies (Ozkol, Zucker, & Spinazzola, 2011) have found differences between boys and girls in terms of the development of PTSD and aggressive behaviors and due to the fact that boys reported significantly more exposure to violence than girls. It would also be important to investigate the difference between the impact of domestic violence and political violence on both boys and girls.

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Appendix Detailed Results

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A. Mothers and Child's Exposure to Traumatic Events Mothers About 60% (57.34%) of the mothers were exposed to at least one traumatic event at some point in their lives. About half of the mothers (47.81%) were exposed to at least one act of political violence such as living amongst rocket attacks or in war zones (37.84%) or they saw, heard or felt a shock, or tremor during an event of falling rockets or a terrorist attack (37.14%). One third (34.30%) experienced other traumatic events including accidents (9.07%), physical assault (3.17% by a stranger), or sexual assault (e.g., 2.26% experienced sexual assault by a stranger). Results are presented on Tables A.1 and A.2. The prevalence of exposure to acts of political violence was higher among Arab mothers (66.84% and 42.94% among Arab and Jewish mothers respectively Table A1.), Israeli born mothers (52.34% among Israeli born versus 29.24% among immigrant mothers- Table A.3), mothers from lower income families (55.60% and 45.08% among mothers with low versus higher family income respectively- Table A.4), and among less religious mothers (51.71% and 27.01% among less religious and very religious mothers respectively- Table A.5). The prevalence of trauma history other than political violence was similar in most groups except for very religious mothers who reported less exposure to non-political trauma than less religious mothers (20.2% and 37.01% among very religious and less religious mothers respectively). It should also be noted that Arab mothers hardly reported on trauma history other than political violence, as can be seen in Table A.2.

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Table A.1: Mothers' Exposure to Traumatic Events (Frequencies, Mean and Standard Deviation) by Ethnicity Exposure to Traumatic Events by Ethnicity Maternal Exposure to at least % one act of political violence Maternal trauma history other than political violence % (at least one act) Maternal Exposure to at least one traumatic event (any % type) Mean Maternal Exposure to Political Violence S.D Maternal Trauma History Mean (other than political S.D violence) Mean Maternal Exposure to any traumatic event S.D

Jews (n=720)

Arabs (n=184)

42.94%

66.84%