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Iraqi children’s war experiences : the psychological impact of "operation Iraqi freedom" Al-Mashat, Kasim Mohamed 2004

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Iraqi Children's War Experiences: The Psychological Impact of "Operation Iraqi Freedom" by Kasim Mohamed AI-Mashat B.B.A., Simon Fraser University, 1998 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS In The Faculty of Graduate Studies Department of Educational and Counselling Psychology and Special Education We accept this thesis as conforming to the required standard The University of British Columbia August 2004 © Kasim Mohamed Al-Mashat, 2004 JUBCL THE UNIVERSITY OF BRITISH COLUMBIA FACULTY OF GRADUATE STUDIES Library Authorization In presenting this thesis in partial fulfillment of the requirements for an advanced degree at the University of British Columbia I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Name of Author (preprint) Date (dd/mrn/yyyy) > f * ) Q 1 Title of Thesis: Year: C^Lo <3 D e 9 r e e : M o P k u c)f Ax1r9 D e P a r t m e n t ° f ^ a u r ^ . m A J ^ J ^ W J //, v, 9 The University of British Columbia Vancouver, BC Canada \ —>- • »—^  " l—^—v. grad.ubc.ca/forms/?formlD=THS pacjfi 1 nf 1 /asf updated- ?.!)-.hi\-(M Abstract This study investigated Iraqi children's experiences of "Operation Iraqi Freedom" and the meaning that the war had for them given their cultural context. Specifically, the study focused on the war experiences of children from the Northern town of Mosul who were exposed to both the missile bombardments during the war and to the fighting that ensued afterwards. In order to better understand the nature of war trauma in children, this study explored the children's perceptions of war experiences and the way in which they made sense of it. In this qualitative study, two focus groups were employed to interview a total of 12 children between the ages of 9 and 13. The children elaborated on either the drawings they made or on the letters they wrote about their war experiences. The Child's Reaction to Traumatic Events Scale (CRTES) was used to gather descriptive statistics on the children's levels of distress. General demographic information is provided. Results from the C R T E S indicate a high level of distress amongst the majority of the children even seven months after the official end of the war in Iraq. A number of themes emerged that pertained to the children's war expereinces, the meaning it had for them, how they coped, and their future hopes. Finidngs were consistent with previous litererature in the field on the psychoglical impact of war trauma on children and their reations to it. This study demonstrates the importance of ideology, faith, and culture in how children make meaning of their traumatic war experiences. Implications for research and counselling psychology are provided, and future research is explored. iii Table of Contents Abstract p. ii Acknowledgments p. v Chapter 1: Introduction p. 1 Research Problem p. 2 The Context of War p. 2 Operation Iraqi Freedom p. 3 Trauma Defined p. 5 Situating the Researcher p. 8 Chapter 2: Literature Review p. 10 Trauma Models p. 10 Table 1: Long-Term Effects of Trauma p. 15 Trauma and Culture p. 22 War Related Trauma p. 25 Children's Resilience p. 26 Development of Psychological Stress Reactions p. 27 Iraqi Children's Previous War Experiences p. 37 Research Questions p. 41 Chapter 3: Methodology p. 43 Instrument p. 44 Procedure p. 45 Participants p. 47 Data Analysis p. 48 Quality of Method p. 50 Using Focus Group Interviews with Children p. 51 Chapter 4: Findings P. 54 Demographics p. 54 Table 2: Demographic Information from Focus Group #1 p. 55 Table 3: Demographic Information from Focus Group # 2 p. 56 C R T E S Scores p. 57 Table 4: C R T E S Results p. 58 Table 5: Anecdotal Totals for C R T E S Scores p. 60 Analysis Through Film p. 62 iv Peer/Audience Response to The Film P- 64 Resonance P- 64 Pragmatic Value P- 65 Coherence P- 66 Compelling P- 66 Contributions P- 68 Themes P- 69 Frightening war stories P- 69 Language of war P- 70 Good equals tough P- 72 Coping P- 73 Severity of traumatic symptoms and effect of war P- 73 Chapter 5: Discussion P- 76 Fit with Literature P- 76 Implications for Counselling Psychology P- 84 Implications for Conducting Research P- 88 Limitations P- 92 Future Research P- 94 References P- 96 Appendices P- 102 Appendix A : C R T E S (English) P- 102 Appendix B: C R T E S (Arabic) P- 104 Appendix C: Consent form P- 107 Appendix D: Iraqi Psychiatrist's Interview Transcript P- 111 Appendix E : Demographic Information Question Sheet (English) P- 119 Appendix F: Demographic Information Question Sheet (Arabic) P- 121 Appendix G: The Children's Drawings P- 123 V Acknowledgements "Turn every stumbling block into a stepping- stone. " — Bruce Lee "Do to us what you will, and we will still love you. Bomb our homes and threaten our children, and as difficult as it is, we will still love you. But we assured that we'll wear you down by our capacity to suffer, and one day we will win our freedom. We will not only win freedom for ourselves, we will so appeal to your heart and conscience that we will win you in the process, and our victory will be a double victory. " — Martin Luther King, Jr. There were many people who have helped me turn every stumbling block into a stepping-stone, allowing for the completion of this project that is hoped to continually appeal to our hearts and consciousness. These individuals have provided me with support and encouragement while sharing their knowledge and wisdom. Dr. Norm Amundson, I would have never imagined working with a thesis supervisor with your kindness, humbleness, genuineness, and wisdom. You allowed me to follow my dreams. You were always a step ahead of me, always knowing exactly how to best guide and encourage me in this journey. Your support was unwavering, complete, and very uplifting. I will always be grateful for everything that you have done. Dr. Maria Arvay, I feel fortunate that you played a vital role in this project. Your insights and experiences were invaluable. Your creativity was inspiring. Without you, this project would not have been the same. Thank you. Your truly are gifted at what you do. Dr. Marv Westwood, I feel privileged and honored to have worked with you. Your support even prior to your involvement in this project had touched my heart. You helped me prepare for my trip to Iraq and embraced me upon my return. You bring the human element to academia. To my friend Paul Engstrom, you truly are a blessing. Without you, the film "The Other Reality" would not have been possible. Your commitment and dedication to the film was unprecedented. You have shown me how friendships truly cross enemy lines, cultures, races and religions. To my parents, you are the anchors of my ship. You kept me afloat during the most difficult times. Your love and support continues to deeply touch me. To my father, the will and drive that you have shown in achieving your life's accomplishments keep on inspiring me. To my mother, I continuously strive to learn from your unconditional love, your kind soul, and your purely unselfish heart. I am who I am today because of both of you. To my grandmother, I cannot even begin to thank you for what you did. You opened your heart, and you embraced me in your house in Mosul. Your strength inspires me. You connected me with family friends who played a vital role in helping me to conduct this research in Mosul. Without you and our family friends, this project would have faced insurmountable obstacles. To my late grandfather, you are the wind in my sails. Your spirit guided me back to Mosul. You will always be in my heart. I will strive to follow your footsteps, continually learn from how you lived your life, and aspire to make you proud. Chapter 1: Introduction At the end of the 20 t h century, one may look back at the historical events that marked it with both marvel and sadness. Marvel at the technological advances and the scientific leaps. However, wars and terrorism have also marked the 20th century. There have been two world wars, hundreds of regional conflicts, civil wars, and terrorist attacks. A n optimist may hope that the beginning of a new century would mark a new and peaceful turn in world events. History, however, seems to be repeating itself in the new millennium. Events such as the horrible attacks on the World Trade Center on September the 11th and the recent war in Iraq are among the events that are marking the beginning of the 21 st century. Unfortunately, children are among the most vulnerable populations that become war casualties. The ones that are spared from the killings or the direct experience of harm seem to suffer deep emotional distress. A literature review on this area has revealed a growing body of research on the psychological distress that children of war suffer. Most studies look at the symptom formation of Post Traumatic Stress Disorder. Studies have been conducted in places such as Rwanda, Israel, Palestine, Oklahoma City, Croatia, Cambodia, Iraq, and Lebanon (Dyregrov, Gjestad, & Raundalen, 2002; Dyregrov, Gupta, Gjestad, & Mukanoheli, 2000; Kuterovac-Jagodic, 2003; Pfefferbaum, Nixon, Tucker, Tivis, Moore, Gurwitch, & Pynoos, 1999; Sack, Seeley & Clark, 1997; Schwarzwald, Weisenberg, Solomon, & Waysman, 1997; Sundelin-Wahlesten & Knorring, 2001; Thabet, 1999). However, the majority of the current studies are quantitative in nature. This tendency in the research was also paralleled in previous research conducted with Iraqi children after the 1991 Gulf War (Dyregrov, Gjestad, & Raundalen, 2002; International Study Team, 1991). 2 Research Problem There are gaps in the literature on war and children that leave a number of questions unanswered. Children's voices are hardly heard while studying their war experiences. There is also very limited knowledge on the meaning that these children make of their war experiences and their perceptions of it. The recent "Operation Iraqi Freedom" exposed Iraqi children to war and its consequences. The research problem of interest was the psychological impact of "Operation Iraqi Freedom" on Iraqi children. This study explored children's war experiences and the meaning it had for them. This will contribute to the field of counselling psychology by providing rich and detailed findings that would help to better understand the nature of war trauma upon children. The Context of War In order to understand the impact of war on children, a brief description of war itself will be discussed. This will provide context to the reader of what war really means. Readers who have not been through a war or experienced the consequences of war may not fully appreciate its' devastating effects on a person, their community, and their environment. This may have been the case with "Operation Iraqi freedom" due to the mostly sanitized war coverage that was provided by the media in North American. A n observation was made from personal experience of being "glued" to the television screen during the time of the war. American television networks, such as C N N and A B C mostly provided sanitized images of war. On the other hand, watching the Arabic news satellite of Al-Jazeera or the English B B C brought the viewers closer to the realities of war. The argument over the morality and suitability of showing gruesome war images is beyond the scope of this paper. Instead, the purpose of this discussion is to bring into awareness the reality of war to the reader. As James Garbarino puts it, the "real essence of real 3 war is terror, dismemberment, disfigurement, peeing in your pants from fear, being splattered with the guts of your friends, chaos so profound you can hardly bear to recognize it from what it is. When asked, 'What was it like?' one soldier replied bitterly, 'It's not like anything. It is just is'" (Garbarino, Kostelny, & Dubrow, 1991, p. 7). The impact of falling missiles in a residential neighborhood may be difficult to comprehend from watching the event on television. What does a missile do? As we have learned years after the 1991 Gulf War, "precision bombing" was not so precise after all. Military strategists may declare the use of missiles as successful tactics. After all, missiles and rockets "wound many more than they kill and thus tie up a lot of resources (not to mention exert a demoralizing force by providing living reminders of the opponent's insistence presence)" (Garbarino et al., 1991, p. 9). Operation Iraqi Freedom On March the 20, 2003, the United States began its military campaign to overthrow Saddam Hussein and occupy Iraq. The strikes began shortly before 6:00 a.m. Iraqi time, less than two hours after the U.S. deadline expired for Saddam Hussein to surrender power (Macleod & Greenaway, 2003). The silence in the city of five million people was shattered by the air raid sirens and the thunderous impact of one missile after the other. The "shock and awe" attack that began on March 22 n d delivered 320 Tomahawk missiles on its first day, which blasted the capital of Baghdad (Duffy, 2003, p. A l ) . U.S. Defense Secretary Donald Rumsfeld told reporters that the campaign was historic in its precision. Rumsfeld argued that the weapons that were being used "have a degree of precision that was never dreamed o f (p. A2). One of the victims of the war in Iraq was the United Nations High Commissioner for Human Rights, Mr. Sergio Vieira de Mello. He was killed in the bombing of the United Nations headquarters in Baghdad on August the 19, 2003 (Office for the United Nations High 4 Commissioner For Human Rights, n.d.). Months before he was killed, Mr. Sergio Vieira de Mello openly shared his deep disturbance by reports of the increasing number of deaths of civilians, as well as injuries, during the conflict in Iraq. On April the 9 t h, 2003, the late Commissioner stated, "the impact on civilians must never be underestimated, for it is truly terrible in a way that words simply cannot convey. This conflict [in Iraq] has reminded us once again of the cruelty of war and that the innocent are invariably its main victims" (United Nations Press Release, 2003). The Commissioner then cited reports from humanitarian agencies, such as the Red Cross, that hospitals could no longer cope with the influx of the wounded. The missiles that fell on Iraqi cities were examples of war's realities. One of the bombardments that received media coverage were the missiles that fell on April the 9 t h 2003 on the affluent area of Al-Mansur, in Baghdad. A n attempt was made to "decapitate" the Iraqi government and kill a large number of leadership in one blow. US intelligence received information that Saddam Hussein may have been in the al-Saa restaurant, in the Al-Mansur area of Baghdad. According to the pentagon, "a leadership target was hit very hard" (Smith and Harnden, 2003, p. A5). To be precise, four GBU-31 "Bunker-Buster" bombs designed to penetrate deep into the target were dropped by flying B l Warplanes. Until this day, US officials have not confirmed the number of leadership personnel that were killed in the bombing. What have been confirmed, however, were the immediate deaths of 14 civilians and an uncounted number of wounded. The impact on the ground was clear, "two houses were flattened and four other buildings badly damaged in the bombing. A l l that was left of the al-Saa restaurant was a crater more than 50 yards wide scattered with debris" (p. A5). Even though this particular bombardment received media coverage, it was only one of the many neighborhoods that were hit. The reality of war was felt in most Iraqi cities. 5 The "precision" bombs were certainly not a "dream." They were gruesome and devastating realities of Operation Iraqi Freedom. Bombs were not precise to the people whom innocently and helplessly lay in the craters of these missiles. Nor were they precise to the children who witnessed their family, friends and relatives lying in ruble and twisted steel. It is a reality that this researcher faced upon traveling to the Northern city of Mosul, in Iraq. This study examined the psychological impact on Iraqi children who were on the receiving end of the United States "shock and awe" campaign. Particularly, the impact of the war and missile bombardment on Iraqi children living in Mosul was examined. Trauma Defined Descriptions and definitions of terms related to the area of trauma will be provided to familiarize the reader with this topic. Both stress and trauma are used in the medical and psychological literature to refer to the "unusual events, significant change or threat demanding special biobehavioral or psychological adaptive responses by the individual in order to maintain psychophysiologic equilibrium and well-being" (Sadeh, 1996, p. 685). The literature refers to the event that triggers the change or threat as the "stressor" (p. 685). For instance, missile bombardment near the homes of children is a stressor since it presents significant threat to their lives. The adaptive responses to stress have been identified by Selye, who is considered to be the founder of stress research (Sadeh, 1996). In his 1956 book, The Stress of Life, Seyle outlined the common components of the adaptive responses to stress. Sadeh (1996) summarizes these components as following: The general adaptive syndrome is characterized by (1) the alarm phase, in which the activity of the adrenocortical system increases dramatically and facilitates hypervigilance, increased activity, and readiness for action; (2) the stage of resistance, 6 which represents the organism's attempt to regain and maintain homeostasis; and (3) the stage of exhaustion, which results from a depletion of the adaptive energies and may cause irreversible damage to cardiovascular, digestive, immune, and circulatory systems, (p. 685) Even though individuals' stress tolerance and modes of responding to the stressors differ, there are similarities in the use of psychological defenses and the development of symptoms as an outcome to a person's attempt to fight the anxiety or flee from it, in the "fight or flight" response (Webb, 1991, p. 3). "Psychological effects" are those that "affect emotion, behavior, thoughts, memory, learning ability, perceptions, and understanding" (Machel, 2001, p. 80). More specifically, psychological trauma is caused by "an extreme event that occurs unexpectedly and suddenly, is life threatening or is perceived to be so, and has intense impact on the senses of the person involved" (Ullmann & Hilweg, 1999, p. 23). The constellation of post-traumatic symptoms that could develop includes behavior, cognitive and physiological clusters (Apfel & Simon, 1996). Terr (1991), a pioneer in children's trauma research, defines childhood trauma as "the mental result of one sudden, external blow or a series of blows, rendering the young person temporarily helpless and breaking past ordinary coping and defensive operations" (p. 11). Children are particularly more vulnerable to stress and post-traumatic symptom formation. Their increased vulnerability is due to their coping repertoire that is more limited because of their youth, immature defenses, and lack of life experiences (Webb, 1991). Interest in psychological trauma has been energized and focused by the definition of clinical post-traumatic stress disorder (PTSD). This definition was made in the Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychiatric Association (Shavlev, Yehuda, & McFarlane, 2000). PTSD has been defined as a clinical disorder resulting from exposure to an overwhelming event. The current definition in the D S M IV-Text Revision (TR) states that the disorder results from exposure to "an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or a threat to physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate" (American Psychiatric Association, 2000, p. 464). The symptoms of PTSD fall into three clusters as summarized by Sundelin-Wahlesten and Knorring (2001): ...(i) recurring intrusive recollection of the traumatic event such as dreams and flashback (re-experience); (ii) persistent avoidance of stimuli associated with the trauma or numbing of emotional responsiveness; and (iii) persistent symptoms of increased arousal characterized by hypervigilance, increased startle response, sleep difficulties, irritability and concentration difficulties, (p. 564) Currently, much is known about the trauma in adult life. However, the consequences of such traumatic events on children have not been studied sufficiently (Sundelin-Wahlesten et al., 2001). Child specific criteria for the diagnosis of PTSD were introduced for the first time in the third edition of the D S M in 1980. The latest DSM-IV-T R does stipulate that PTSD may manifest itself differently in children than adults. For instance, a child's fearful response may be observed by disorganized or agitated behavior. A child's re-experienced symptoms may be observed in his or her playing out some aspects of the trauma. Children's dreams may also include distressing themes that may not include recognizable content. Children also feel a sense of "foreshortened future," 8 which can be evident in their belief that they will not live long enough to become adults (American Psychiatric Association, p. 464). Acute Stress Disorder (ASD) is another D S M IV-TR diagnostic disorder that has recently received attention in the psychological trauma literature. Bryant and Harvey (2002) provide a comparison between A S D and PTSD. The structure of A S D diagnosis follows that of PTSD in that it is described in terms of the definition of the stressor, re-experiencing, avoidance, arousal, and duration. A S D is distinguished from PTSD by its emphasis on the dissociative cluster of symptoms. To satisfy the criteria for this cluster, three out of the five dissociative symptoms need to be present: numbing or detachment from expected emotional reactions; reduced awareness of the surrounding; derealization (i.e., a perception that the world is unreal or dreamlike); depersonalization (i.e., a sense that one's body is detached); and dissociative amnesia (i.e., the inability to recall critical aspects of the trauma). This description of A S D and its' distinction from PTSD was provided to expose the reader to the terminology that is frequently used in the studies that will be examined later in the discussion. This will also increase the awareness of the reader on the spectrum of psychological reactions that children of war may suffer. It should also be pointed out that the aim of this study was not focused on researching the development of PTSD or A C D in Iraqi children. The study was interested in non-specified disorders. In other words, the focus of the study was on the lived experience of the children that may include symptoms of anxiety, depression, and/or fear. Situating the Researcher In 1974,1 was born in the city of Mosul, in North of Iraq. I became an Iraqi exile living in Canada shortly after the 1991 Gulf War. Even though over fifteen years have passed since the 9 last time I set foot in my hometown, my ties remain very strong and deep to my native country. Watching the war from a distance was a deeply painful experience. It touched the core of my heart and soul. I asked myself "how could 1 watch the war while sitting in the comfort of my home in Vancouver, British Columbia?" A sense of guilt, anger and helplessness overwhelmed me. Sleepless nights left me pondering on what family, friends, and Iraqis in general were going through in Iraq. The war also had a positive impact on my life. It forced me to question my values and true passions. It allowed me to experience an epiphany. M y research needed to focus on Iraqi children's experience of the war. Looking back, I certainly can say that the war triggered a shift in my career path. I decided to change my thesis topic and dedicate my work to the Iraqi children who experienced this war. The decision to research the impact of war on Iraqi children became an obvious and clear choice. However, it also presented a personal challenge. I strongly identified with Garbarino's (1993) argument that few issues challenge our moral, intellectual and political resources as does the topic of children and war. One of the challenges that he identifies is that "we must force ourselves to both think and feel about the children of war. We must be willing to engage in objective analysis at the same time we open ourselves to the pain and horror" (Garbarino, 1993, p. 787). If we do rise to the challenge, argues Garbarino, it becomes growth inducing. I decided to rise to the challenge and strive to remain objective while opening myself to the horrors of war in Iraq. 10 Chapter 2: Literature Review This literature review is organized in a manner to provide the reader with an overview of the most relevant areas of both childhood trauma and the effects of war related stress on children. First, models on children's adaptation to stress and trauma will be covered. This will provide the theoretical underpinning for the study. Secondly, an exploration of the cultural effects on the manifestation of traumatic symptoms will be provided. This will serve as a critique of the existing western paradigms and will reveal a need to account for cultural variations in the experience of trauma. Thirdly, in an attempt to understand the stress of war, specific war-related trauma will be examined. Lastly, the focus will be on reviewing studies that research the impact of war on children. Trauma Models Veltkamp and Miller (1994; Miller & Veltkamp, 1988) propose a model that conceptualizes children's adaptation to stressful events. Even though their theory was developed for children that experienced sexual abuse and emotional trauma, this model may be useful for understanding the stress of war on children. Their model is called the Trauma Accommodation Syndrome, which consists of five stages. Stage I of the response involves a child experiencing an event that is life threatening, threatening serious injury, or threatening the child's physical integrity. Stage II is a phase that is characterized by the child's reenactment of the trauma, repetitive play, frightening dreams, or avoidance. The child's response in this stage may also involve fear, helplessness or horror. Stage III involves re-occurrence of intrusive and distressing recollections of the stressful life experience. The response in this stage may include distressing images, thoughts or dreams. The re-experiencing of the trauma is often observed through repetitive play that may include trauma 11 related themes. Children may also elicit disorganized or agitated behavior. Stage IV involves cognitive processing. A triggering life experience could lead to trauma reevaluation or re-examination of the physical or psychological trauma. In this stage, the child puts effort toward reasoning through reconsideration of the traumatizing process. This allows the child to revisit the trauma, get a better understanding of it, and be able to mourn the experience. In the final stage of trauma accommodation, the child is able to resolve or accommodate the traumatic issues. In this stage, coping strategies may allow the child to accept the meaning of traumatization to his/her identity. This adaptive incorporation of meaning may permit the child to resolve the traumatic experience without doubt or guilt. Even though Veltkamp and Miller's (1994) model proposes a specific theory on children's adaptation to sexual and emotional abuse, their theory does shed light on childhood trauma. Therefore, this model was presented to orient the reader on the general context of childhood trauma. Briere (1992, 2002) proposes another model that is based on childhood abuse and neglect. This model will also serve as a way to further orient the reader on the subject matter of childhood trauma. The Self Trauma Model incorporates trauma, cognitive and behavioral, and self-psychology theories. Briere considers trauma as a disorder of the memory. However, in contradiction to classical pathology models, the Self Trauma Model suggests that the post-traumatic stress symptoms are not just symptoms of dysfunction. In fact, he argues that symptoms such as intrusion and avoidance may be an "inborn self healing activity," and serve an important psychological function, "that of repetitive reactivation and processing of traumatic memories to the point that they lose their distress" (Briere, 2002, p. 182). Briere suggests that the only reason we are traumatized is due to our evolution. Our memory is an evolutionary adaptation that results in our ability to carry forward our adversities from the past. Yet, Briere 12 admits that not all individuals exposed to a traumatic experience, such as sexual abuse, will necessarily develop significant post-traumatic symptoms. Briere agrees with existing theories that link the development of post-traumatic stress to a variety of pre-trauma variables. These variables include temperament and biologically based vulnerability to stress, the presence of preexisting psychological difficulties that reduce stress tolerance, and exposure to previous trauma. In addition to these variables, Briere's Self Trauma Model suggests that a significant component of one's response to trauma is the degree to which the stress overwhelms one's ability to handle its effects through "self-capacities," particularly "affect regulations" (p. 181). According to Briere, self-capacities are a series of behavior and responses that are related to ones sense of self and how one relates to others. Extreme stress, then, results from a "mismatch" between the overwhelming trauma and inadequate affect regulation (p. 181). The mismatch could be a product of normal affective capacities that are insufficient and fall short from being able to deal with an extreme trauma. Affect regulation could also be inadequate to deal with the trauma if an individual's affect regulation is insufficiently developed. This would be the case with people that were exposed to early child abuse or neglect. These children are exposed, according to Briere, to "insurmountable affective obstacles," such as sexual abuse and psychological maltreatment (p. 180). Given the danger and ongoing physical and emotional pain, affect regulation skills are less likely to develop. Instead, these children use other coping means such as dissociation, thought suppression, distraction or other avoidance strategies. As a result from their inadequate affect regulation, abused children are unable to regulate their emotions and may be seen as moody, emotionally hyper-responsive, and overreact to stressful events in life. 13 Exposure to early trauma in life also renders a person with more dysfunctional coping strategies later in life. According to Briere, the more trauma a child is exposed to earlier in life, the worse the post-traumatic symptoms will be later in life and the more problems the individual will face. A person will be more likely to react to negative affects by engaging in "external behavior that distract, soothe, numb, or otherwise reduce painful internal states, such as substance abuse, inappropriate or excessive sexual behavior, aggression, binging or purging, or even self injury" (Briere, p. 181). From the Self-Trauma Model two relevant points emerge relating to war and children. Firstly, the traumatic experiences of war may trigger earlier trauma suffered by a child. In other words, children who were exposed to earlier trauma in their life may overreact to the stressful events of war. This is only a hypothetical assumption that is being made. Proving this notion is beyond the scope of this paper. However, what emerges is a better understanding of the complexity of reactions that children of war may exhibit given their possible earlier traumatic experiences. Secondly, assuming that children of war have not been exposed to earlier traumatic life experiences, the war may overwhelm the child's normal affective regulation and render this capacity insufficient and inadequate to cope with the stress. In this hypothetical situation, the traumatic experiences of war may be the building block for more severe reactions to later _ stressful life events. How could that be possible? Van der Kolk (1996, 2002) describes how exposure to events that overwhelm the organism's coping mechanisms can damage the self-regulatory systems that are needed to assist the physiological and biological changes to return to a normal state after the traumatic event. Van der Kolk makes a distinction between the persistent reliving of trauma in people with PTSD and ordinary memory. In ordinary memory, a person does not usually relive the images, smells or 14 physical sensations related with an event. Instead, the person remembers ordinary events in narratives that capture what happened. With traumatic memory, on the other hand, an individual is not able to assimilate or integrate their experiences: Their 'implicit' (sensory and emotional) memories of the trauma are 'dissociated' and return not as ordinary memories of what happened, but as intense emotional reactions, nightmares, horrifying images, aggressive behavior, physical pain, and bodily states. The mental imprints of the trauma return, (van der Kolk, 2 0 0 2 , p. 4 ) Van der Kolk describes the neurobiology of trauma in different parts of the brain. Under conditions of intense trauma, the more primitive parts of the brain generate sensations that allow an individual to respond to the stressful stimuli in the fight or flight reaction. One part of the brain that is identified as being central in the traumatic reexperiencing is the limbic system. Particularly, a section called the amygdala interprets the emotional significance of the experiences. It forms emotional memories in response to particular sensations and is believed to be extremely difficult to extinguish (van der Kolk, 2 0 0 2 b ) . These changes in the brain and altered functions in other parts (such as hippocampus and thalamus) seem to prevent trauma imprints from being organized into a narrative by the higher brain's autobiographical self. Instead, trauma imprints seem to be stored as fragmented sensory and emotional traces. According to van der Kolk, most people do not realize that their current intense feelings and reactions are based on past experiences. When confronted with experiences that include certain elements of the original trauma, such as smells or sensations, a person with PTSD may react as if they were going through their traumatic experience again. In other words, when the sensations of the new experience match the imprint from the original trauma, their biological systems are activated and they are retraumatized. Therefore, it is safe to suggest then that the traumas suffered be Iraqi children could become the building block for more severe reaction to stress later in life. Table 1 highlights other long-term effects of trauma. Table 1 was adapted from van der Kolk (1996b, p. 184). Table 1 Long-Term Effects of Trauma • Generalized hyperarousal and difficulty in modulating arousal: Aggression against self and others Inability to modulate sexual impulses - Problems with social attachment—excessive dependence or isolation • Alterations in neurobiological process involved in stimulus discrimination: Problems with attention and concentration Dissociation - Somatizaiton • Conditioned fear response to trauma-related stimuli • Shattered meaning propositions: Loss of trust, hope, and sense of agency - Loss of "thought as experimental actions" • Social avoidance: Loss of meaningful attachments Lack of participation in preparing for future Attachment is another area related to trauma that van der Kolk refers to that seems relevant to this discussion. Attachment refers to the "affectional bond that forms between a nurturing figure, usually the mother, and child in course of time and in response to consistent care" (Gordon, Farberow, & Maida, 1999, p. 99). When infants engage in 16 normal play and exploratory activities they rely on the presence of a familiar attachment figure that modulates their physiological arousal. The capacity of a mother to modulate physiological arousal reinforces the child's attachment to her and provides cues to the infant to engage in alteration between exploration and return to the mother. If a child is exposed to unmanageable stress and the caregivers do not take over the function of modulation of the child's arousal, the child will be unable to organize his/her experiences in a coherent fashion. This will result in the child's inability to regulate emotional states and have problems integrating incoming information. A child's ability to process information seems to be powerfully affected by early patterns of attachment (Streeck-Fischer & van der Kolk, 2000). A reinforcing and consistent attachment, on the other hand, seems to help children cope with overwhelming stress, such as war related stress. In one of the earlier studies on children and war, Anna Freud reported some of the accounts on children exposed to World War II (Freud & Burlingham, 1943). She found that children that were exposed to bombardment and were in the care of their own mothers did not seem psychologically devastated by their wartime experiences. As children grow older in their normal development, their need for physical proximity to the mother gradually decreases. This is replaced by increased social play that is expressed in attachment to the father and peers (van der Kolk & Fisler, 1994). The adolescents use their peer group as an intermediary stage between dependency on their family and emotional maturity (van der Kolk, 1985). Van der Kolk found the men that developed PTSD after combat in Vietnam tended to be adolescent while in combat. The PTSD group in his study also had a more tightly knit "buddy" network and they experienced more deaths to people they felt close to. Their intense attachments to other men were severed, which often followed by retaliation and feelings 17 of helplessness. He found that soldiers with PTSD reacted to the losses as a "narcissistic injury rather than as an object loss" (p. 368). Van der Kolk elaborates: "It was the younger men who had experienced the death of a friend and the concomitant dissolution of the once omnipotent group as a narcissistic injury and who had persistent nightmares of the traumatic events, in which they regularly relived the state of helplessness they once had experiences on the battlefield" (p. 368). In short, a child or adolescent's attachment to family and peers is an important factor that contributes to their psychological well-being. This will be kept in mind when analyzing the findings from in this study. Van der Kolk's theory on traumatic memories and trauma "imprints" will also be explored in the discussion of the findings. This will allow for the exploration of how war trauma may have affected the children in Iraq and the way in which they shared their narratives. Kocijan-Hercigonja (1999) discusses children's reactions to wartime stress. Based on work with Croatian children exposed to war trauma in the former Yugoslavia, Kocijan-Hercigonja proposes that children go through three phases. In the first phase, they are confronted with new situations resulting from their exposure to the war. At this stage children experience violence or injury, seek safety in cellars or flee, and endure separation or loss. Kocijan-Hercigonja suggests that most children exposed to war experience at least one of these situations. This phase is characterized by "acute post-traumatic disturbances" (p. 159). These disturbances manifest in a child's refusal to eat, an altered emotional state, sadness, frequent crying and a general sense of being unsure. In this stage, some of the children want to see their father help and protect other people. Some wish that their father or brother would wear a military uniform. They identify with soldiers and want to dress as soldiers. 18 Not only do children suffer numerous loses and are confronted with emotional and physical trauma, they are forced to live under different conditions. Facing unfamiliar conditions, such as a refugee camp or a war torn community, characterizes the second phase of war trauma. Children experience difficulties adjusting to this new surrounding with sometimes incomplete family, and with different roles within the family structure. Children are also suddenly confronted with strangers and other languages. Kocijan-Hercigonja suggests that some of the children lose respect for their parents and lose the special meaning they used to hold for them. This is especially true when children compare their parents to the parents of their new friends, whether in refugee camps or in their new homeland. The child becomes ashamed of his own parents and origins. In addition to prevalence of PTSD in many children at this second phase, Kocijan-Hercigonja suggests that the children also develop behavioral disorders such as aggression, depression and communication disorders. Kocijan-Hercigonja's third phase relates more to refugee families. In this stage, the family makes the decision to either stay in the new location permanently or return to their homeland. Children that returned home experience a combination of good and horrible memories of their homeland. At this phase, argues Kocijan-Hercigonja, PSTD becomes more severe in many cases. This often happens when the child was not able to process their losses and experiences. Children realize that their reality is drastically different from their dreams of returning home. This phase is often characterized by very strong emotional reactions, such as distressing nightmares and suicide attempts. Even though Kocijan-Hercigonja does shed light on the trauma reactions of children exposed to war, it seems that the discussion is specific for children who left their homes and experienced refugee life. The three phases that Kocijan-Hercigonja provides are elaborations on work experiences with Croatian children. It is not a researched trauma theory or 19 model. Hence, the framework was provided as tool to familiarize the reader with the general reactions of children exposed to war. Terr (1991) provides a theoretical model of childhood trauma. Her model is based on her own work, such as her research on the Chowchilla school bus kidnapping (Terr, 1981, 1983). Terr provides an organized scheme of thinking about childhood trauma. She suggests broadening our view of childhood trauma from the mere clinical diagnosis. In fact, argues Terr, if we only look at the clinical manifestation of childhood trauma on a given day, we can end up with multiple diagnostic disorders, such as Conduct Disorder and Attention Deficit Hyperactivity Disorder. By only focusing on the diagnostic fine points we also lose sight of a central point, "that external forces created the internal change in the first place" (Terr, 1991, p. 10). Terr describes childhood trauma as having four primary characteristics. These are derived from several prominent characteristics that distinguish trauma in children: thought suppression, exaggerated startle response, sleep problems, developmental regression, fears of the mundane, deliberate avoidance, panic, irritability and hypervigilance. However, Terr distinguishes four primary characteristics since these characteristics can be observed "no matter when in the course of the illness one observes the child and no matter what age the child is at the time" (p. 12). One of the four primary characteristics of childhood trauma is a child's experience of strongly visualized or repeated memories. This ability to re-visualize and re-feel a terrible event can be stimulated by reminders of the event or they may be experienced when they are entirely uninvited. A second primary characteristic in childhood trauma is that they engage in repetitive behavior. Play or behavior reenactment are listed as frequent consequences of single and long-term terror in children, and the children are normally unaware of their own behavior. Behavior reenactment can occur either as a "single behavior, repeated behavior, or bodily response" (p. 20 13). Terr argues that behavior reenactment may become a distinct personality trait if it occurs frequently. A third characteristic of childhood trauma is the experience of trauma specific fears. These are fears of specific things that are related to the experiences leading up to the traumatic event. For instance, according to Terr, fear of dark and being alone are strongly connected to the experience of shock in children. Lastly, children that experience trauma also go through a change in attitudes about people, aspects of their lives, and their future. They develop a sense of a foreshortened future. Through their experiences, children come to recognize the vulnerability of human beings. This observation is similar to what Garbarino (1998) terms "Snowden secret" (p. 362). From his own work, Garbarino observed that children exposed to violent trauma learn about "dark secrets" about the world (p. 362). Snowden secret is what children come to understand of what happens to a human body exposed to violent trauma. Garbarino elaborates on this secret: "Snowden's secret is that the human body, which appears strong and tough is really just a fragile bag filled with gooey stuff and lumps. This knowledge is itself traumatic; it changes you forever" (p. 362). Terr further argues that childhood trauma can fall into two types. Type I trauma refers to the reaction that can follow a single event. This type of trauma resembles PTSD since it usually meets the criteria of repetition, avoidance, and hyper-alertness. This type is not preceded by a previous trauma. Type I is characterized by detailed memories, omens, and misperceptions. Terr suggests that children who witness one terrible event have an ability to remember details efficiently, and they do not often forget their account. "Omens," is a term that Terr uses to describe children's attempt to retrospectively regain control over the randomness of the traumatic experience (Terr, 1991, p. 15). 21 The last characteristic of Type I trauma is misperceptions. This includes "misidentifications, visual hallucinations, and peculiar time distortions" (p. 15). Terr argues that even though these perceptual distortions may seem to indicate organic mental conditions, massive releases of brain neurotransmitters may be the cause. On the other hand, Type II trauma results from repeated and long standing exposure to extreme events. Type II reactions can be characterized by massive denial, psychic numbing, self-hypnosis, dissociation, aggression towards self, identification with the aggressor, and personality changes. Denial and psychic numbing are typical finding of post-traumatic stress disorder. Children use denial and psychic numbing to suppress their thought and may seem withdrawn. Self-hypnosis and dissociation are also used by children to escape mentally from their trauma. Terr provides an example of a child repeating certain words to escape from their pain and worry. Lastly, rage develops in Type II trauma where trust was originally involved prior to the trauma. Terr further stipulates that there are two main conditions that result in the cross over manifestation of both Type I and Type II characteristics. For instance, this may involve a single psychological shock resulting from losing ones parents. A child's mourning may not proceed in its normal stages in such cases. The other condition is the traumatic incident that involves a child's disfigurement, disability or pain. These children, according to Terr, perpetually mourn their old selves. By looking at the characteristics of both Type I and Type II trauma it is safe to suggest that most children who live through a war may develop reactions that crossover between these two types of trauma. After all, children who are exposed to extreme trauma and repeated traumatic experiences are particularly susceptible to the development of psychological trauma (Ullmann & Hilweg, 1999). Based on Terr's model, one would expect that Iraqi children would have 22 crossover reactions. Since Terr provides such an elaborate an organized way of thinking about childhood trauma, her model will be revisited in the discussion of the findings. Trauma and Culture The models presented above share a common paradigm. They were developed based on western cultural paradigms. What impact does culture have on the validity and reliability of these models on non-western cultures? There are many definitions that have been suggested for the concept of culture. Al-Issa (1982) suggests that most definitions regard culture as "those aspects of the environment that are man-made, including the subjective environment, which consists of the beliefs, values, norms, and myths that are shared by the group and symbolically transmitted to its members, as well as the physical environment, which is comprised of artifacts like roads, bridges, and buildings that are handed down from one generation to another" (p. 3). Western cultural theories of mental disorder and trauma are about personal and social events. These notions draw upon "cultural assumptions concerning the nature of ordinary personal experience and social interaction in order to interpret behavioral disturbances which are regarded as extraordinary, abnormal or disruptive" (Marsella & White, 1982, p. 14). After all, trauma models follow the logic of western notions of psychiatric illness. By only following the western notion of psychiatric illness we may risk being ethnocentric, especially when we engage in "inquiring how such conditions are dealt with in other societies where the idea is not used and, hence, where some persons showing 'mental and emotional disturbances' may not be defined as ill," and that they "may not necessarily be handled in a different way from other ill persons as the case in Western societies" (Fabrega, 1982, p 45). Thus, one can safely suggest that trauma models that have been developed in western cultures have been woven from the cultural fabric that comprises them. 23 Kleinman (1987) suggests that by imposing the standard approach of mental illness in cross cultural research, we are committing "a category of fallacy," which he defines as "the reification of nosological category developed for a particular cultural group that is then applied to member of another culture for whom it lacks coherence and its validity has not been established" (p. 452). He argues that interpretations are judgments that stem from reliability of consistently applying certain measures. However, argues Kleinman, we need to develop validity by establishing an understanding of the particular cultural context being studied. In another noteworthy article, Kleinman (1987b) argues that our western notions on theories of mental health have resulted in medical classifications, such as the D S M classification of PTSD. Kleinman suggests that our desire to use a medical model of classification turns diagnosis into reductionism. This means that we "want to classify cultural bound syndromes, not as a separate domain of experience, but within the technical terminology of international psychiatry" (Kleinman, 1987b, p. 49). It should be pointed out, however, that this argument does not imply that individuals in non-western cultures do not experience PTSD like symptoms nor is it implying that PTSD is not real. Instead, to better understand the manifestation of these symptoms and their impact, the cultural context and meaning it has for individuals from non-western cultures needs to be accounted for. Young (1995), who is another authoritative critique of diagnostic models, further argues that PTSD has been confirmed empirically by its place in people's lives. The suffering is real. However, Young suggests that traumatic memories is not a found object that has always existed, rather, it is a socially constructed one that originated in scientific debates of the nineteenth century. He argues that: 24 ...the generally accepted picture of PTSD, and the traumatic memory that underlines it, is mistaken. The disorder is not timeless, nor does it possess an intrinsic unity. Rather, it is glued together by the practices, technologies, and narratives with which it is diagnosed, studied, treated, and represented and by the various interests, institutions, and moral arguments that mobilized these efforts and resources. (Young, 1995, p.5) Are there constraints in using PTSD in the current literature regarding children's reactions to war? In her literature review of our current understanding of children and war, Berman (2001) raises the concern of the limited scope in which PTSD is currently defined. Berman suggests that the symptoms comprising PTSD are only one form of reactions to the traumatic experience of war. Cairns (1996) also suggests that the expression of psychological trauma in non-western children who experience war and violence is more complex than simply counting symptoms of pathology. By using a general model of trauma with children from non-western societies we are unconsciously relying on the assumptions based on these western models. A number of assumptions are highlighted in Derek Summerfield's (1999) article, entitled "A Critique of seven assumptions behind psychological trauma programs in war affected areas." One of these assumptions covered is our belief that western psychological frameworks capture a universal human response to highly stressful events. The problems with this assumption, argues Summerfiled, is that the western view of trauma is individually centered and regards the human being as a single unit of study. This results in our desire to emphasize the similarities and plays down the differences in diversity. This assumption of the medical model is also echoed in Jo Boyden's (1994) work. Boyden suggests that the medical approaches "tend to ascribe social 25 problems to individual pathology, favoring individualistic interpretations of child suffering" (p. 256). Gibbs (1994) argues that the utility of the medical model of trauma is increasingly being brought into question. He found that even when the medical models seem universally valid to those from Western European traditions, concepts of childhood and suffering are different in non-western cultures. Gibbs (1994) elaborates his point by stating, "the distinctive cultural web of Mozambique, interwoven with its particular social, political, and economic threads, influences both the way the community understand and acts on the needs of its children" (p. 271). In other words, cultural and contextual factors seem to shape the experience of trauma. This is what Kleinman refers to as "social suffering" (1995, p i 89). Thus, we could better understand trauma as a form of social suffering and not as isolated experiences. This also implies that the meaning behind children's war experiences is culturally and socially situated. Therefore, to understand the psychological impact of the war on children, the researcher needs to explore the meaning that these experiences have for them given their cultural context. War Related Trauma In order to understand the psychological impact of war on children, a specific identification of war related traumas will be examined. Kocijan-Hercigonja (1999) worked with Croatian children and identified three categories of trauma that children suffer: "Direct war-related traumata," "indirect war-related traumata," and "traumata closely related to living in that country" (p. 159). Direct war-related traumata are those events that children experienced themselves. This includes children who were wounded, lived in prison camps, lost their parents or were mentally and/or physically abused. The "indirect" war related traumata results from children that witnessed violent acts or murder, and lost their relatives and friends. The third 26 category of war-related traumata is linked to living in the country of war. This type of trauma results from the sudden change in rules or customs that the children were used to. Suddenly, the meaning and validity of those rules become unstable, a child "does not understand why many things are no longer the way they were" (p. 159). Macksoud, Dyregrov and Raundalen (1993) conducted an extensive literature review on the topic of war trauma and children. They highlight nine traumatic experiences that children face during war: violent death of a parent; witnessing the killing of close family members; separation and displacement; terror attacks, kidnapping, and life threat; participation in violent acts; witnessing parental fear reactions; physical injuries and handicaps; and, extreme poverty and starvation. This list of experiences was complied from different countries. Since each country experiences a distinct type of war, the types of traumatic experiences could vary from country to country. Macksoud et al. suggest that the type of war related traumata should be kept in mind when assessing the impact of war trauma on children. They argue that both the magnitude of the traumatic exposure (i.e., how many traumata) and the extent of exposure (i.e., how often and for how long) need to be kept in mind when looking at the effects of war trauma. Children's Resilience Before we begin examining the studies on the psychological impact of war on children, the issue of children's resilience needs to be raised. Some studies have reported little effects of wartime stress on children. For instance, in their literature review, Jensen and Shaw (1993) refer to a number of studies conducted in Israel in the mid-seventies that suggest war has a limited effect on children. Accepting children's resilience as a generalized and absolute concept takes away the responsibility from adults. This may minimizes the consequences of our actions that lead to war and terrorism. 27 Indeed, some children may be somewhat more resilient to the effects of trauma. Children under the age of three have no sense of fear for a realistic threat and that suggests that they may be more immune to psychological trauma (Sundelin-Wahlesten & Knorring, 2001). Before the age of three, children's verbal memory has not developed. When those children are exposed to trauma, they only have the ability to register basal sensory stimuli. These stimuli include sounds, light and colors. Sundelin-Wahlesten et al. suggest that children under the age of three do not experience trauma on the same emotional level that older children do. However, even these young children are impacted without their own awareness. Traumatic stress reaction during this early phase of development may surface as restlessness, excessive screaming, failure to thrive, regressive psychomotor development and demanding behavior (Sundelin-Wahlesten & Knorring, 2001). Development of Psychological Stress Reactions There seems to be a number of factors that contribute to the severity of the traumatic symptoms that develop in children exposed to war (Dyregrov, Gupta, Gjestad, & Mukanoheli, 2000; Dwivedi, 2000; Eth & Pynoos, 1985; Macksoud, Aber, & Lawrence 1996; Pynoos & Nader, 1993). A n attempt was made to identify those prominent factors from the reviewed literature, and then include them in distinct categories. Unfortunately, the studies that were examined did not fall into neat categories. These studies did not simply investigate a single contributor to the development of psychological trauma and its impact on children. It can not simply be isolated and traced back to a single causal variable. According to the literature that was examined, the severity and variations of psychological reactions in children seem to vary depending on the interplay of a combination of factors (Dyregrov, Gjestad, & Raundalen, 2002; Pfefferbaum, Nixon, Tucker, Tivis, Moore, Gurwitch, 28 Pynoos, 1999; Sack, Seeley & Clarke, 1997; Schwarzwald, Weisenberg, Solomon, & Waysman, 1997; Sundelin-Wahlesten & Knorring, 2001; Thabet, 1999). It should be pointed out, however, that the contributing factors are by no means exhaustive. They are some of the main factors that emerged from the studies that will be examined next. Some of these factors include the amount of exposure to the stressor, the reactions of adults and family to the trauma, and the child's development level (Dwivedi, 2000; Eth & Pynoos, 1985; Pynoos & Nader, 1993). An examination of some of the current literature will illustrate these points. Macksoud, Aber, and Lawrence (1996) quantitatively examined the war experiences of Lebanese children who grew up during the war in their country. The study examined the number and type of war trauma and the relation of such traumatic experiences to the children's psychosocial development. Two hundred and twenty four children between the ages of 10 to 16 were interviewed from all major geographical regions and religious groups. The children were interviewed using measures of war exposure, mental health symptoms, adaptational outcomes, and PTSD. This included the Childhood War Trauma Questionnaire, the Child Behavior Inventory, and the Post Traumatic Stress Reaction Checklist. One of the interesting findings was that the number of war traumas experienced had no effect on mental health symptoms or adaptational outcomes. Instead, different types of traumas predicted different developmental outcomes. They found that out of the 10 types of war traumas they examined, four accounted for variance in the Lebanese children's development outcomes: separation from parents, bereavement, displacement, and witnessing violent acts (such as witnessing bombing our shelling). They found that these specific war traumas seemed to burden children's development by imposing PTSD and depressive symptoms. For instance, by using Post-Traumatic Stress Reaction Checklist, the researchers were able to measures PTSD symptoms in relation to one 29 trauma. Out of the 224 interviewed children, 96 children isolated and selected one trauma that was most disturbing for them during the war. The most commonly selected disturbing traumas were: "witnessing the killing of family member," "having one's home directly hit by a shell," or "being caught under the fire of a militia fighter" (p. 76). The experience of living through bombardment seems to be one of the top disturbing events that impacted Lebanese children. Another quantitative study was comprehensively conducted to examine children's reactions to the genocide in Rwanda (Dyregrov, Gupta, Gjestad, & Mukanoheli, 2000). A total of 3,030 children aged 8 to 19 years old were interviewed about their experience and reactions. This was conducted approximately 13 months after the genocide that started in 1994, in which 1 million people were killed from the population of 7.5 million. The researchers used the children's version of the Impact of Event Scale questionnaire. This questionnaire focuses on intrusive images, avoidance of reminders, arousal signs and associated post-traumatic stress reactions. Virtually all the children in the sample had witnessed some kind of violence. The authors used exposure variables that were grouped into three indices: loss of family members, threat of dying, and violent exposure of different types. The authors' multivariate analyses showed that exposure was related to the degree of intrusive memories, thoughts, and arousal. Children with high intrusion and arousal scores had lost someone, experienced violent exposure, and felt threatened. In fact, threat had the highest influence on intrusion and avoidance in the study. The children's exposure to the horrific genocide also seems to have affected their attitudes. More than 90% of the children believed that they would die during the war, and about one third worried that they would not live to become adults. 30 The authors compare the diagnostic cut off score for PTSD on the Impact of Event Scale with the children's scores. Seventy nine percent of the children interviewed had higher scores than the minimum cut off for PTSD diagnosis. More importantly, these scores were obtained more than a year after the genocide. The authors do point to caution in interpreting this information as evidence for PTSD; however, it definitely indicates a high degree of distress. In other words, time alone did not alleviate the psychological trauma experienced by the children's exposure to the genocide. In addition to the relation between exposure and psychological trauma, children's reactions are also mediated by their parent's response to the events (Meire, 2002). In the case of the Rwandan children, the extent of loss and trauma affected all levels of society. This could have rendered the coping mechanism of parents and adults less viable, and less receptive to the needs of these children given their own grief (Dyregrov et al., 2000). In other words, fragmentation of community and less parental support seems to predispose children to higher emotional disturbance in times of war. The significance of attachment and bonding can be understood as deep emotional and biologic needs that are crucial for the survival in both humans and animals (Sadeh, 1996). Any disruption to the attachment need can be experienced as a serious threat. Particularly, significant distress is experienced when the child feels in danger of losing a major source of security and support. This premise was illustrated in a study that investigated the responses of middle and high school students that were exposed to the 1995 Oklahoma City bombing. In this quantitative study, questionnaires were administered to 3,218 students 7 weeks after the explosion (Pfefferbaum, Nixon, Tucker, Tivis, Moore, Gurwitch, Pynoos, & Geis, 1999). Validated questionnaires were used (such as the Impact of Event Scale) to measure the children's 31 exposure, personal consequences, initial response and current post-traumatic stress and other symptoms. They used both parametric statistics (analysis of variance) and nonparametric statistics (chi2) to examine between group differences in category of loss. Four categories of loss were used: loss of friend or acquaintance; loss of other relative; loss of parent or sibling; and no loss. They found that the mean post-traumatic stress symptom score for bereaved youth was higher than the mean score for any other group. They also found that bereaved youth were more likely than non-bereaved youths to retrospectively report symptoms of arousal (shaking and trembling), intrusion, nervousness and fear. In addition, seven weeks after the bombing 14.7% of the total sample reported that they still did not feel safe and 62.8% reported worrying about themselves or their families. There was also difference between the bereaved and non-bereaved children in regards to their fear, worry and safety. One third of those who lost a parent or sibling reported not feeling safe at all, while only 11.9% of the children who did not lose anyone reported similar feelings. This study sheds light on the effect of loss on psychological trauma resulting from a terrorist bombing. The studies above reflect the general trend in the current research on the topic of war and children. Most studies quantitatively research the formation of PTSD symptoms in relation to war related variables, such as exposure or loss. For instance, in another study, the researchers estimated the rate of post-traumatic stress reaction in Palestinian children who experienced war trauma (Thabet, 1999). The children were selected for their behavioral and emotional problems that were observed by teachers in the initial screening process. The researcher used multiple quantitative instruments in gathering and analyzing data, such as the Rutter A2 (parent) and B2 (teacher) scales, and the Child Post-Traumatic Stress Reaction Index. The finding suggested that 32 73.2% of children (from the sample of 239) reported PTSD reaction of at least mild severity, and 39% reported moderate to severe reaction. One study conducted in Israel comes closer to employing qualitative methods in their research. They examined how children's cognitive views of the future related to the degree of exposure to trauma and to their post-traumatic stress reaction (Schwarzwald, Weisenberg, Solomon, & Waysman, 1997). A total of 492 Israelis school children participated in the study from grades 5, 7, and 10. These children had experienced the Scud missile bombardment during the 1991 Gulf War. Questionnaires were used to assess the children's perceived stress and postwar stress reaction three weeks following the Gulf War. Some of the instruments used where the Global Symptom Score and the Child Post-Traumatic Stress Research Index. More importantly, they used open-ended questions to assess what the children thought life would be like the next year in Israel for children their age. However, this usage of qualitative procedure was adopted only to gather information that would allow them to analyze the relationship between postwar stress reaction and perceptions of the future. There was little deviation from the use of quantitative approaches in analyzing and discussing their findings. For instance, they reported in their findings that children with higher levels of postwar stress reaction also reported a more pessimistic view of the future. Given the purpose of this study, the data collected from the qualitative part of a research was not used to analyze emerging themes in the children's cognitive thoughts on the future. This type of analysis could provide the reader with a significant and rich understanding of children's perceptions after their traumatic war experiences. Nevertheless, this study did reveal the impact of children's exposure to missile bombardment on their perceptions and cognitive views. The children that showed stronger postwar reactions expressed a more pessimist view of the future. 33 Goldin, Levin, Persson and Hagglof (2001) conducted a qualitative study that examined the stories of Bosnian refugee children's war experiences. They interviewed ninety children two years after the end of the war in Bosnia. The participants came from refuge families who were assigned to Umea, Sweden, during 1994-1995. The children and adolescent's ages were between one and 20 years. A semi-structured interview was conducted with the whole family of the child, and school aged children (7 years or older) were interviewed alone. Out of the 90 children, 81 were assessed for their experience of war, the remaining nine were not born at the time of war. The authors propose a method for "structuring, ranking and comparing clinically derived child stories of pre-war, war and exile" (p. 26). They used quantitative analysis to present their qualitative findings. Their method of analysis, unfortunately, can easily confuse the reader. Their purpose in embarking on a qualitatively rich study was reduced to numerical reporting. Their analysis was complex and required the reader to reread their findings in order to understand what information was being conveyed. Findings were broken down into numerous tables that divided the children's stories into certain incidences, such as explaining the differences between war and exile experiences by socio-demographic background factors. After carefully reading their results, a number of children's experiences could be highlighted. The stories demonstrated that children were able to share painful and terrifying events with detailed richness. However, the authors do not share what these experiences were. The children also idealized the past as a strategy to cope with their feelings of loss and victimization. Goldin et. al also found that age significantly differentiated the children's experiences in wartime. They found that "pre-school children dominated in the war cluster least exposed; primary school age children and teenager were over-represented in the cluster most targeted" (p. 43). The authors suggest that older children were less sheltered and had greater freedom and independence to 34 move, thus, resulting in greater war exposure. The authors began by providing a rational for allowing these children's voices to be heard. Due to the method of data reporting, however, the reader may not get a real complete sense of these children's experiences and voices. Nevertheless, this study is one of the few studies that qualitatively examines war experiences of refugee children. Berman (2001) conducted a literature review on the topic of children and war. She also found that most of the current research on children's response to wartime trauma is primarily quantitative in nature and focuses on PTSD outcomes and measurement. This is also consistent with studies that were published after Berman's review (Allwood, Bell-Dolan, and Husain 2002; Dyregrov, Gjestad, and Raundalen, 2002; Kuterovac-Jagodic, 2003; Sundelin-Wahlesten, 2001). Few studies qualitatively examine children's experience of war. A qualitative study would provide an in-depth exploration of children's experiences of their war trauma and the meaning it has for them. Berman (1999) ventures into the field of war trauma and children in pursuit of understanding how children "make sense" of their violent experiences (p. 57). Berman's work seems pioneering in this area. In her study, she explores the experiences of two groups of children that grew up amid violence. She uses a convenient sample of 16 refugee children that experienced war and 16 children of battered women. The children's ages ranged from 10 to 17 years. The primary instrument used was an unstructured interview that consisted of open-ended questions, which was designed to elicit the children's story about violence in their lives. The participants were given the choice of being interviewed individually or in a group format. The themes that emerged were shared with the children and revised with them to actively involve them in the construction of meaning. Berman found that despite the differences in stories between war children and children of battered women, they shared many parallels. Since children's experience of war is a particular interest in this paper, a closer look will be provided on Berman's finding that pertain to this group. Berman found that the refugee children often spoke about happy times and treasured memories prior to their war experiences. Their normal and mostly peaceful life was suddenly intruded upon by the beginning of fighting. Even though the children experienced tensions in their countries (Burnudi, Somalia, Liberia, and Bosnia) prior to the war, the eruption of war was perceived as sudden and unexpected. Children vaguely understood the purpose of the fighting. Nevertheless, these children were able to recall and remember precisely the actual events that occurred, including what they saw and heard. Berman also found that the most valid way to describe these children is that they felt betrayed, angry and confused. The children exposed to war endured a tremendous amount of pain and suffering. Many children shared the losses they suffered. They shared experiences of lying awake at night listening to the sounds of war outside their homes. However, they were able to share their experiences communally and collectively with family, friends and neighbors. One of the Berman's most encouraging findings was that many children expressed a sense of confidence and optimism. Some felt that they were "lucky" to have escaped and survived. Children also expressed that they did not feel that they could ever forget their experiences; yet, they also did not express a desire for revenge. Using the same data from the above study, Berman (1999b) also researched the understanding and experiences of health, and the relationship between health and violence for war children and children of battered women. The original data that was used for the above two studies was gathered for a larger work on critical narrative research (Berman, 1996). Again, the 36 main aim of her study was to give voice to children's experiences and meaning while keeping in mind their social and political context. The same sample and the same narrative data analysis methods were used. Four categories or themes emerged from Berman's main interview question on the what health meant to the children: "Not being sick, being able to do what you want to do, being mentally healthy and happy and stuff like that, and just getting through the day" (Berman, 1999b, p. 95). For instance, "just getting through the day" category represented the children's modest definition of health. The children viewed health as a necessary everyday functioning that allows them to sleep through the night and to feel safe. Even though many of the children were living outside the war zone during the interviews, many still suffered both physically and emotionally. Their sense of security in the new country was fragile and easily threatened. For example, some of the children feared an outbreak of war in Canada during the time that Quebec held a referendum on separation. Events such as fireworks also triggered fears and intrusive images. The problems that these children experienced were summarized by Berman: "(a) loss of sleep, (b) intrusive thoughts, (c) eating disturbances, (d) difficulty carrying on with daily routine, including school, (d) lack of energy, and (e) self-doubt and the lack of confidence in themselves and the world around them" (p. 105). Berman's findings provide crucial knowledge that helps us understand what refugee children's experiences are and what meaning it has for them. This critically significant type of qualitative study seems limited or lacking in research on children who experience war but remain in their homeland. 37 Iraqi Children's Past War Experiences Few studies within the last decade have examined Iraqi children's war experiences. There are two studies of particular relevance that examined children's experiences of the 1991 Persian Gulf War. The focus of these studies and their research methods, however, seems to parallel the majority of the existing literature. The studies are mostly quantitative in nature and their main focus is on PTSD outcomes and measures. A recent study has been published that researched the psychological effects of the 1991 Gulf War on Iraqi children over a two year time period (Dyregrov, Gjestad, & Raundalen, 2002). The group was exposed to the bombing of the A l Ameriyah shelter where more than 750 people were killed. A total of 94 of the original 107 children (response rate of 88%) living close to the shelter were interviewed three times - at 6 months, 1 year and 2 years after the war. The children and adolescents' ages ranged between 6 to 18. Semi-structured interviews were used to gather information on demographics, loss, separation, and exposure to war. The Impact of Event Scale was used to summarize the impact of trauma on the intrusion and avoidance dimensions. In addition, a number of other measures where also included such as the Post Traumatic Stress Reaction Checklist, War Trauma Questionnaire, and the Child Behavior Inventory. The authors used sophisticated statistical data analysis methods such as analysis of variance, statistical software for item analysis, and chi square tests. The majority of children reported that they felt unhappy (sometimes or always) at all three time points. Eighty percent continued to experience fear of losing their family over the three time points. The majority also reported experiencing irritability and concentration problems. Around 80% of the children experienced levels of traumatic stress that exceeded the cut off threshold, suggesting that cases meet the criteria for PTSD diagnosis. This percentage remained 38 stable over time. They also found that younger children (those under 11 years of age) were less bothered by intrusion than older children. Even though younger children initially showed less distress, it was found that older children (those between 14 and 17 years of age) evidenced the greatest reduction of distress. This suggests the existence of more cognitive strategies in older children to deal with stress. The authors also suggest that high levels of avoidance and intrusion among Iraqi children may render them less able to process the trauma, which places them at high risk for psychiatric impairment. The majority of the findings in this study were presented, as was the case in the other studies examined, using quantitative research methods. A small part of this study, less than a paragraph, highlighted the non-quantitative impressions and information gathered from the interviews. The authors indicated that many children were told by their parents to forget their experiences. This left them feeling alone with grief and distress. These findings suggest that children wanted to share their experiences and wanted their voices to be heard. Their feelings and the perceived meaning of their experiences, however, were not captured by the methods employed in this study. After all, as with the majority of studies discussed, this study's main focus was the quantitative measurement of PTSD symptom and its development. Another key study was conducted in Iraq six months after the cease-fire from the 1991 Gulf War (International Study Team, 1991). This study employed both qualitative and quantitative research methods. From August 23 to September 5, 1991 the International Study Team on the Gulf Crisis conducted a comprehensive and in-depth survey on the impact of the 1991 Gulf war on the health and welfare of the Iraqi population. One of sections in the report was entitled "Child Psychology Survey" (p. 1). In this study, 214 Iraqi children of primary school age were interviewed to assess the impact the 1991 Gulf War. Half of the children were sampled from A l -39 Ameriyah neighborhood in Baghdad, which was the site where a shelter was bombed; the other half were sampled from the city of Basra, in the south of the country. In their assessment, the researchers used the Impact of Events Scale, the Post-Traumatic Stress Reaction Checklist, and the Child Behavior Inventory. More importantly, the authors elicited in dept interview information regarding the children's experiences of the war. This methodology included the use of picture drawing, play and story writing. Results from the Impact of Event Scale revealed the children were exceedingly bothered by intrusive thoughts six months after the war. The children also had difficulty keeping inner images of war from disturbing them. A common response was "I try everyday, but it is impossible not to be thinking about it" (p. 5). Results from the Post-Traumatic Reaction Checklist revealed that the majority of the children suffered from anxiety and fear. Fifty percent of the children continued to dream about the war. Sixty six percent of children had difficulty sleeping because of their memories, and 63% had difficulty with concentration. In addition, three quarters of the children found little joy in playing with friends, sports, or other activities. Sixty two percent of the children also worried that they may not live to become adults. The authors found that the most worrisome feature of the results from the Child Behavior Inventory was the high proportion of children that experienced sadness and worry (75% of the children). The children worried for the survival of their family and needed the presence of an older person to feel safe. During the interviews a theme of guilt emerged. The majority of children felt the burden of depression and guilt because they survived when their friends or relatives did not. The children interviewed also expressed confusion about what really happened and about the reasons for the war. Some children expressed a victorious anti-American version for the war with some talking about revenge. 40 In the concluding comments of the authors they state the following: The most serious conclusion to be drawn from this material is that what happened to these children-the severe psychological trauma- might cause them serious problems for years to come. For some children, these problems may endure for their entire lifetime....The children interviewed strive to frame and understand what they saw; planes bombing, houses collapsing, fire burning, soldiers fighting, mutilated and cursed bodies, and burned out trucks. The children fight to forget what they heard; people screaming, desperate voices, planes, and explosions. The children are haunted by the smell of gunfire, fuel from planes, fires, and burned flesh. Many children are still struggling with the memories of what they touched: remains of planes, blood, dead bodies and wounded relatives, (p. 12) Another important finding in this study was one of the observations made by the researchers. They observed that "adults constantly underestimate what their children have, in fact, experienced, and how their children suffer psychologically from such experiences" (p. 13). This finding also indicates that children seem to want to share their experiences and want their voices to be heard. This study provides evidence on the psychological trauma and distress that Iraqi children experienced during the 1991 Gulf War. However, their findings were mostly dedicated to analyzing the quantitative data gathered. The qualitative data obtained were briefly elaborated on in some sections of the report. The qualitative findings were largely used to support the quantitative data examined. A more detailed report on the qualitative data gathered would have provided the reader with even a greater appreciation of the children's experiences and their voices. For instance, what were the questions asked in to elicit story telling in the qualitative 41 interview? What did the drawings of the children reveal? What themes emerged from the stories and writings of the children? Nevertheless, the findings from this study provided compelling and disturbing evidence on the psychological trauma suffered by Iraqi children during the 1991 Gulf War. The majority of the literature on the psychological impact of war on children seems to be quantitative in nature. These studies focus on PTSD as the main outcome measure. They examine PTSD formation in relation to a number of different factors, such as exposure, cognitive abilities, parental support and loss. Few qualitative studies ventured into the children's world in order understand their experiences. Most of the qualitative studies examined, however, focused on the experiences of refugee children. The experiences of refugee children could be different from the experiences of children that remain behind in their homeland. The gaps in the literature were also paralleled in the studies that specifically researched the impact of the 1991 Gulf War on Iraqi children. These studies are mostly quantitative in nature and have examined PTSD symptoms and its' development. A qualitative study could provide a significant and rich understanding of children's perceptions of their traumatic war experiences and the meaning it has for them given their cultural context. Research Question It was shown that Iraqi children had suffered psychological trauma during the 1991 Gulf War and that the children seemed to want their voices to be heard. The recent war on Iraq provided a new generation of Iraqi children exposure to war and its consequences. This study took a qualitative approach in answering the research question "What were Iraqi children's experiences of'Operation Iraqi Freedom' and what meaning did the war have for them given their cultural 42 context." To better understand their experiences and provide these children with a voice, a focus group approach will be the employed as the main data collection tool. 43 Chapter 3: Methodology This was a qualitative study with a qualitative research design. The research method was selected to answer the question of interest: "What were Iraqi children's experiences of 'Operation Iraqi Freedom' and what meaning did the war have for them given their cultural context." Particularly, the focus of this study was on the experiences of the children that lived through missile bombardment in the Northern city of Mosul, in Iraq. A focus group interview was employed to give voice to the children's experiences. Kleinman highlights the pitfalls of not giving voice to participants and their cultural meanings: "we, each of us, injure the humanity of our fellow sufferers each time we fail to privilege their voices, their experiences" (Kleinman, 1991, p. 117). This study privileged the children's voices. Listening to the children's voices has advantageous outcomes. In fact, Berman (1999a) states that "by talking with children, encouraging them to examine their own ideas about violence in their lives, by providing a context in which they can openly and safely reflect upon their responses, as well as the response of those around them, they become empowered" (p. 62). This study empowered the children by giving them an opportunity to share their experiences. This seems to have helped them to begin processing their exepierinces, their feelings, and their thoughts. The group dynamic also allowed them to normalize their feelings and it validated their experiences. Focus group interviews were also chosen for a number of other reasons. Focus group research in general does intent to promote self-disclosure among participants (Krueger & Casey, 2000). It allows the researcher to know what the participants are thinking and feeling. As Krueger et al. have suggested, the focus group interviews in this study proved to be a powerful tool since children had a tendency to disclose things about themselves in conversation with others. This may not be the case in all studies. Nevertheless, the tendency of self-disclosure in focus groups leads to an ethical implication in conducting research with war-traumatized children, which will be elaborated on later in the discussion. It should be pointed out here, however, that researchers need to be delicate in their questioning since talking about specific traumatic experiences may trigger an emotional reaction in a child. Krueger et al. also found that an individual's decision to reveal information is based on their perception of others in the group. Participants in this study tended to disclose more about themselves since the other children were similar to them. The participants were comprised of a relatively homogenous group. They shared a common experience of surviving war in particular neighborhoods. A focus group also has another advantage, "a group possesses the capacity to become more than the sum of its parts, to exhibit a synergy that individuals alone don't possess" (p. 25). The focus group discussions seemed to have triggered or brought to awareness thoughts and feelings that the participants may have had suppressed. The participants seemed to feel comfortable in sharing their experiences since the moderator strived to provide a permissive, non-judgmental and non-threatening environment. Lastly, the focus group was chosen since the group setting acted as a "safety net" that supported and minimized emotional breakdowns. In summary, the safe environment established through the focus group interviews privileged the children's voices, enhanced their self-disclosure, empowered them, and provided them with an opportunity to process some of their experiences. Instrument The Child's Reaction to Traumatic Events Scale (CRTES) was used to gather descriptive statistics on the children's level of distress (Jones, 1994). This was not used as a diagnostic measure of PTSD. The C R T E S is a psychological measure designed to assess psychological 45 responses to stressfull life events. See Appendix A for a copy of the instrument, and Appendix B for an Arabic translation of the scale. The C R T E S is a revision of the Impact of Events Scale (Horowitz, Wilner, & Alvaraz, 1979). It is a 15 item self report questionnaire to measure intrusive thoughts, affects, and avoidance behaviors in children and adolescents. Respondents are asked to use the most recent and significant stressful life event as a reference to complete this scale. This scale normally takes between 5-10 minutes to administer. The C R T E S uses a four-point frequency rating scale that targets the Intrusion and Avoidcance criteria of the D S M IV (APA, 1994). The frequency rating scale includes the following: "not at all" (0), "rarely" (1), "sometimes" (3), and "often" (5). A total score higher than 28 suggest a high degree of distress. The C R T E S has been used with children exposed to different traumatic events. It has been used with children exposed to fires (Jones & Ollendick, 2002; Johes & Ribbe, 1991; Jones, Ribbe, & Cunnigham, 1994) and with children exposed to hurricanes (Jones, Ribbe, & Cunnigham, 1993). Studies have demonstrated the reliability and validity of the scale. In a study following Hurricane Andrew, test of internal consistency yielded Cronbach's alpha scores of .84 for the Intrusion subscale, .72 for the Avoidance subscale, and .85 for the total scale (Jones et al., 1993). In a study of 71 African American children residing in a high crime and low income area, the internal consistency for the total scale yielded Cronbach's alpha of .73 (Cunningham, Jones, & Yang, 1994). Cronbach's alpha for the Intrusion subscale was .68 and .53 for the Avoidance scales. The C R T E S is a validated instrument that was used to assess the children's level of distress in this study. Procedure This study was conducted in the Northern city of Mosul, in Iraq, seven months after the official end of the war. The researcher originally considered conducing this study in Baghdad. 46 Due to logistical difficulties and to the escalating situation, research in Baghdad was not possible. The researcher's family and personal connections also made the option of traveling to and staying in Mosul a more feasible one. This also allowed the researcher to safely blend in with the locals without being seen as "a foreigner." This was paramount in Iraq where safety was a major concern. Convenience sampling was used in this study. Participants were found in Mosul through personal contacts and through a Psychiatrist who helped to locate children living in her neighborhood. The initial plan was to use non-probabilistic purposive sampling. This would have allowed for the recruitment of participants through advertisements and flyers posted near areas that were exposed to missile bombardment. However, upon my arrival in Iraq, it became abundantly clear that the procedure of recruiting participants through this method would not work. The chances for receiving calls that are initiated by participants and their parents were slim to none. This was due to the lack of security and the persistent fear and distrust amongst Iraqi people. People were afraid of being perceived as working on a "foreign" project. This might have put their lives at risk if the insurgents perceived them as being American collaborators. At the same time, people were afraid of being perceived by the Americans as conspirators that were gathering in areas to plot against them. Hence, while keeping the children's safety in mind, the researcher relied on personal contacts in Mosul to assist in the recruitment of children. From the recommendations made by the University of British Columbia's Behavioral Research Ethics Board, verbal consent was obtained for this study. A written and signed consent was not sought since it could have created anxiety and fears of repercussion. Since the former Iraqi regime was repressive and ruled by terror and persecution, Iraqi parents would have felt worried and anxious about signing a form that resembles a legal document. Therefore, the content of the consent was explained, and verbal consent was obtained. The consent form is attached in Appendix C . The children were given four questions to reflect upon. They were given the option to either address these questions by writing a letter or by making a drawing that tells their story. Participants where then asked to share their work in the focus group interviews. The four main questions asked were: a) What was your experience of the war? b) What meaning did the war have for you? c) How are you doing now? What helped you cope? d) And what are your hopes for the future? Two focus groups were employed. One focus group consisted of four children, while the second consised of eight children. The focus groups took about an hour and a half each. At midpoint the focus groups, there was a short 10-15 minute break in which refreshments where offered. At the end of the focus group, the children were given prizes for their participation. Random draws were made for these prizes. Participants A l l of the children that participated in this study were exposed to missile bombardments during the war and lived through the fighting and violence that ensued afterwards. The sample consisted of 12 children between the ages of 9 and 13. A maximum age limit of 13 was imposed in order to avoid the possible issue of retraumatizaiton resulting from a child's exposure to the 1991 Persian Gulf War. Six of the children were males and six were females. Inclusion criteria for participation in this study included the following: 48 1. Children between the ages of 9 and 13. 2. Children who were able to articulate their experiences. 3. Children who were not incapacitated by their war experiences. 4. Children who were willing to volunteer their time to the research. 5. Children who were willing to participate in a focus group. 6. Children who were suitable for focus group discussions. In other words, children that had social and communication skills. 7. Children who lived in the Mosul and experienced living through a missile bombardment. It should be noted here that there was a criterion for only including children scoring less than 28 on the C R T E S . However, this criterion had to be modified. Due to the difficulty of finding participants scoring less than 28 on the scale, the selection criteria had to be revised. The original concern was that children with high scores may be incapacitated by their experience and may not be suitable for the study. However, after talking to the children and building rapport with them it was determined that despite their high scores they were still suited for the study. Data Analysis Data analysis was conducted by following Krueger and Casey's (2000) methods. They suggest that analysis begins by going back to the intent of the study. This study attempted to understand Iraqi children's war experiences and the meaning it had for them given their cultural context. Thus, the purpose of the study was kept in mind when determining the depth or intensity of the analysis. Krueger et al. provide a practical framework for focus group analysis that is systematic, sequential, verifiable, and continuous. The analysis was systematic since it was deliberate and planned. It was sequential since it was an evolving process. Combining both a systematic and 49 sequential analysis ensured that the results reflected what was shared in the focus group. The analysis also needed to be verifiable in order to avoid "selective perceptions" (p. 128). In other words, another researcher should be able to arrive at similar conclusions using the same data. Krueger et al. also argue that in order to ensure an analysis is verifiable "there must be sufficient data to constitute a trial evidence. The data stream begins with field notes and recordings taken during the focus group, continues with oral summary (verification) of key points during each group," and "includes transcripts if used" (p. 128). The researcher followed these guidelines to ensure verification of analysis, as it will be explored in the next section. Analysis was also continuous. Data analysis was done concurrently with data collection. Probes were anticipated and clarifications where sought when participants responses were trivial or unclear. Data was analyzed by using the Kruger et al. transcript-based method. The audiotapes were translated to English and transcribed. Each line was numbered to quickly help locate it in the transcript. Once the tapes were transcribed, the "long-table approach" was used to analyze the data (p. 132). This method allowed the researcher to identify themes and categorize results. Two hard copies of the transcript were used. One copy remained intact while the other one was used in the core elements of this method, which were "cutting, sorting, and arranging through comparing and contrasting" (p. 137). The responses to the four main focus group questions were separated and emerging categories within these sections were examined. Quotes that had similar responses were put together. They were rearranged until their grouping was satisfactory. During this process, decisions were made on the weight given to the comments. This decision was based on four factors: Frequency, specificity, emotion, and extensiveness (Krueger et al., 2000). Although it was important to pay attention to how frequent something was said, it was also important to pay attention to key insights. More emphasis was given to comments that 50 were more specific. More weight was also given to themes or comments that "show emotion, enthusiasm, passion, or intensity in their answers" (p. 136). Lastly, extensiveness refers to the number of times different individuals say something. Attention was paid to extensiveness in analyzing the themes that emerged. Quality of Method Focus group interviews have received extensive attention in the market research field. The success of this method led academics to reexamine its potential for focus group research in the early 1980s (Krueger et al., 2000). When academics began using focus groups they brought with them several strategies that contributed to the method's quality. They sought openness, rigor, and trustworthiness. Krueger et al. highlight a number of characteristics that contribute to the quality of this method. Firstly, social sciences use the same approaches as market researchers but they make adaptations to fit the human experiences. Thus, "focus group research is scientific research because it is a process of disciplined inquiry that is systematic and verifiable. It is not the type of scientific research that seeks to control and predict, but it is the type that seeks to provide understanding and insight" (p. 199). Secondly, they argue that findings frorn focus groups are not just subjective opinions. Systematic steps are used in the analysis to identify key points. For instance, for each point or themes that were identified in this study, "a trail of evidence [was established] that can be verified" (p. 199). Therefore, a careful distinction was made between what was said in the focus groups from the researcher's interpretations. To achieve this end, a number of procedures were set in place. The researcher maintained journal entries. This captured the researcher's thoughts, feelings, and reflections on the process of conducting the focus group interviews. The researcher also maintained observation notes taken during the focus 51 groups. These steps clearly identified and separated the researcher's interpretations from the data provided by the participants. To ensure that the results were trustworthy and accurate, a number of steps were also taken. The questions used in the focus groups were pilot tested to ensure that participants in the study understood them. In addition, during the actual focus group interviews, the researcher carefully listened to participants, observed how they answered the questions, and obtained clarifications when responses were ambiguous. The researcher provided summary comments and asked the participants to verify these comments. The data from the focus groups were also translated and transcribed by using both audio and video recordings from the focus groups. There was also another procedure that was originally planned as a further validity check, but was not implemented. It was originally planned that after the completion of the study, participants would be provided with copies of the transcripts and findings. A package containing this material would have been mailed out to the participants in Iraq. The participants would have then returned their feedback to the researcher in Canada by an enclosed prepaid shipping envelope. This procedure was not feasible due to the escalating situation in Iraq, and due to the lack of postal service in the country. However, another procedure was added to ensure the trustworthiness and accuracy of the results. The findings from the focus groups were verified and elaborated on by an Iraqi Psychiatrist living in Mosul. The transcript from her interview is included in Appendix D. In short, an accepted protocol was followed that ensured that the results were valid, trustworthy, and accurate. Using Focus Group Interviews with Children Focus group interview as a method of research is established as viable research tool with adults. Focus groups are also utilized in research with children. There are a number of areas that 52 focus groups have been used with children, such as in research on child and adolescent health and risk behavior, in research examining children's knowledge and beliefs about AIDS, and children's perceptions of siblings with emotional disabilities (Charlesworth & Rodwell, 1997). Charlesworth et al. discuss the use of focus group interview in child sexual abuse program evaluations. They conclude that "the focus group method is an example of an innovative, and highly feasible resource for data collection," and that "the focus group should be embraced as an effective means of entering and understanding the child's perspective" (p. 1214). The effectiveness of focus groups is also echoed in another article that examines methodological considerations of this method in pediatric research with children aged 6 to 12 (Kennedy, Kools, & Krueger, 2001). They argue that focus groups are an innovative approach that captures children's perspectives, ideas, and insights. It also captures children's experiences from a developmental perspective. This can be achieved by using "relatively homogeneous groups, common cultural emotional, and cognitive process," that allow responses to be revealed "that normally would not come to light in structured data collection" (p. 184). Examining studies that have used focus group interviews with children will further illustrate the effectiveness of this method with specific research problems. Morgan, Gibbs, Maxwell and Britten (2002) examined the experiences of children living with asthma. They used eleven focus groups with a total of 42 children aged 7 to 11. The focus group provided new insight into children's own experiences of asthma. It also identified some important differences from adult's priorities and concerns. The authors suggest that the "focus group are a valuable method for eliciting children's views and experiences" (p. 5). Neumark-Sztainer, Story, Perry and Casey (1999) used focus group discussion to assess adolescents' perceptions about factors influencing their food choices and eating behaviours. The 53 study included 141 adolescents in 21 focus groups that were in grades 7 and 10. This method allowed the researchers to capture multiple factors that effect children's food choices. Parker and Logan (2000) examined students', parents' and teachers' perceptions of primary health care needs of school-aged children. The student sample consisted of seven students from one elementary school located in South Carolina. The use of focus group in this study allowed the participants to "interact together, share experiences, and give investigators greater insight and better understanding of the issues under discussion" (p. 65). Focus groups have also been used with children of middle-eastern cultural background. MacMullin and Odeh (1999) conducted a study to identify and understand the things that worry children in the Gaza Strip. The study was comprised of multiple parts. In the first part, 194 children from Gaza aged 8 to 14 were asked to generate lists of things that they worry about. This data was then used to construct questionnaires that allowed them to rank order the worries and explore developmental and gender differences. In the final part of the study, focus groups were used to allow the children to elaborate on their worries. The children spoke about the strategies they used to manage their concerns and offered advice for younger children that may face similar concerns in the future. In short, these studies illustrate the effectiveness of using focus group interviews as a research tool when working with children. 54 Chapter 4: Findings Twelve children were interviewed in this study. Two focus groups were employed. The first focus group consisted of four children, while the second group consisted of eight children. General demographic information will first be provided. Then, descriptive statistics will be used to examine results from the C R T E S . Lastly, the qualitative data will be analyzed and emerging themes will be highlighted. Demographics The majority of the children interviewed were living in Mosul at the time of the war. Only one of the twelve children interviewed in Mosul happened to be in Baghdad during the beginning of the war. Participant # 7 from Focus Group # 2 was visiting the residential area of Al-Mansur in Baghdad when the war begun. As it was stated earlier, this residential neighborhood in Baghdad was heavily hit by missile bombardment during the war. Besides participant # 7 from Focus Group #2, all of the other children interviewed were living in Mosul during the war. The children in Mosul were also exposed to the war, whether it was by witnessing missile bombardments or by being caught in the fighting that ensued afterwards. The children from Focus Group # 2 lived near the main palace area of the former Iraqi president Saddam Hussein, in Mosul. It was one of Saddam's palaces that were targeted by the American army. Due to the close vicinity of the children's homes to the palace, they lived through missile bombardments and intensive fighting. The children in Focus Group # 1 also experienced missile bombardments. They lived close to the area that contained a number of government buildings and Iraqi intelligence headquarters in Mosul, which were also targeted during the war. 55 Demographic information was gathered from both focus groups. The children filled a demographic sheet that had nine questions (see Appendix E and F). Table 2 and Table 3 highlight some of the demographic information that was gathered. Table 2 Demographic Information from Focus Group # 1 Participant Age Ml F Employment of working parent #of sibling # of family lost during war #of injured family or friends Moved # 1 9 M Government employee 1 1 (aunt died of heart attack while in shock) 0 Yes. (moved for three months) #2 10 F Out of work 5 1(aunt died during the war) 1 (father had a stroke and became half paralyzed during missile attacks) Yes. (moved for three months) #3 10 F Government employee 1 1(aunt died during the war) 0 Yes. (moved for three months) #4 9 F Disabled due to the war and Unemployed N/a 1 (cousin was shot by the Americans) 1 (father was injured) Yes. (moved for two months) 56 Table 3 Demographic Information from Focus Group # 2 Participant Age M/ F Employment of working parent #of sibling #of family lost during war #of family or friends injured Moved #1 12 M Psychiatrist and retired military officer 5 0 0 Yes. (moved for four days) #2 12 F Retired Military officer 3 0 0 Yes. (moved to uncles house for 4 days) #3 12 F Retired 0 0 0 No #4 12 F Military officer 6 0 1 (cousin injured during the war) Yes. (moved for 21 days) #5 12 M Garment salesman 4 0 2 (father and uncle injured) Yes. (moved to grand-parent's house during war) #6 N/a M N/a N/a N/a N/a N/a #7 13 M Cargo driver 1 0 0 No #8 12 M Retired 0 1 (grand-father) 0 No 9 57 Six of the children were males and six were females. Their ages ranged from 9 to 13 years old. Their socioeconomic status seemed to range from lower middle class to upper middle class. It was culturally inappropriate to ask the children the income level of their parents. Thus, their socioeconomic status was determined by looking at the type of work that their parents were involved in, which is a common cultural indicator of wealth and status in Iraq. Some of the occupations were truck drivers, government employees, military officers, a garment salesman and a psychiatrist. Due to the war, a number of the children's parents were out of work, and some had recently retired. The number of siblings that the children had ranged from 0 to 6. The mode number of sibling was one. Some children experienced the loss of a family member during the war. Five children reported the death of a family member during the time of the war. It should be noted here that three of the children that reported the loss of a loved one from Focus Group # 1 were cousins. They indicated the death of their aunt who had a stroke during the war. Another child reported the death of his cousin, who was shot by the Americans. Only one child from Focus Group # 2 reported a loss, which was the loss of his grandfather during the war. A total of four children from both focus groups also reported knowing someone from their family that was physically injured but survived during the war. Eight of the children reported that they had temporarily moved out of their houses at some point in time during the war. This meant moving in with other relatives. This seems to have been a common practice during the war, which helped families gather in safer locations and be together with other relatives. At the same time, the children reported missing their houses and had to adjust to the new temporary living arrangements. Some had moved away for months while others returned to their homes after fours days. CRTES Scores The scale was administered to gather descriptive statistics on the children's levels of distress. As mentioned earlier, this scale is not a diagnostic tool for PTSD. However, it is a psychological measure to assess children's response to stressful life events. One child did not complete the questionnaire. He had to leave during the administration of the scale. From the results of the C R T E S , only one child scored lower than 28 on the scale. Only Participant # 4 from Focus Group # 2 had a score of 20 on the scale. Ten out of the eleven children who filled the scale scored higher than 28. These scores indicated a high level of distress. Table 4 lists the children's individual scores. Table 4 CRTES Results Participants C R T E S scores Gender Focus Group # 1 Participant 1 Participant 2 Participant 3 Participant 4 Focus Group #2 40 M 35 F 35 F 31 F Participant 1 Participant 2 Participant 3 Participant 4 Participant 5 Participant 6 Participant 7 Participant 8 37 M 37 F 32 F 20 F 34 M N/a M 41 M 45 M The median score was 35. It seems that males scored slightly higher on the scale. The range of scores for the males was between 34 and 45, while the female scores ranged between 20 and 37. However, this difference was not observable during the focus group discussions. The 5 9 themes that have emerged in this study were consistent with both genders. In other words, war seems to override gender differences in reactions to trauma. Table 5 provides the reader with further descriptive information on each question on the scale. The total numbers of checked items under each question for all children were compiled in the table. For instance, in response to question number one on the C R T E S , 6 children checked "not at all," 4 checked "rarely," 1 checked "sometimes," and 0 checked "often." In other words, a total of ten children either rarely or didn't think about the war when they did not want to. This suggests that the majority of the children had control over their thoughts regarding their war experiences, over the past week. These numbers have no statistical significance. Instead, this information provides anecdotal data that could be an interesting point for discussion. A number of observations were made from the above calculations. These observations will be explored next. The children's scores to question number three were interesting. The majority of children (7 out of 11) scored "not at all" or "rarely" to "I tried not to remember." It seems that the children had difficulty attempting to forget their war experiences since the environment of war and violence continued to be present around them. Children's answers to questions number four and number six also seemed interesting. The data from question number four suggests that the majority of children (8 out of 11) either rarely or did not have difficulties falling or staying asleep. However, most of them (7 out of 11) indicated in question number six that they "sometimes" or "often" did dream about the war. It seems that even though most children did not have difficulties falling asleep, they still dreamt about their war experiences. Also of note was the children's responses to question number nine. Most children (9 out of 11) "sometimes" 60 Table 5: Anecdotal Totals for CRTES Scores Not at all Rarely Sometimes Often 1. I thought about it when I didn't mean to. Combined totals 6 4 1 0 10 1 2. I stopped letting myself get upset when I thought about it or was reminded of it. Combined totals 0 6 4 1 6 5 3. I tried not to remember. Combined totals 4 3 4 0 7 4 4. I had trouble falling asleep or staying asleep because pictures or thoughts about it came into my mind. Combined totals 3 5 0 3 8 3 5. I had strong feelings about it. Combined totals 4 5 2 0 9 2 6. I had dreams about it. Combined totals 0 4 4 3 4 7 7. I stayed away from things that reminded me of it. Combined totals 4 4 2 1 8 3 8. I felt that it did not happen or that is was make-believe. Combined totals 0 2 5 4 2 9 9. I tried not to talk about it. Combined totals 0 3 3 5 3 8 10.1 kept seeing it over and over in my mind. Combined totals 3 3 3 2 6 5 11. Other things kept making me think about it. Combined totals 3 5 1 1 8 2 12.1 had lots of feelings about it, but I didn't pay attention to them. Combined totals 2 2 5 2 4 7 13.1 tried not to think about it. Combined totals 1 3 5 2 4 7 14. Any reminder brought back feelings about it. Combined totals 2 5 4 0 7 4 15.1 don't have feelings about it anymore. Combined totals 2 3 2 4 5 6 61 or "often" felt that their war experiences "did not happen or that it was make believe." It seems that most children may have coped by denying or dissociating from their experiences. Most children also seemed to have either suppressed or ignored their feelings about the war. This was suggested in their replies to questions number 12 and 13. On both questions, most of the children (7 out of 11) scored "sometimes" or "often" to the statements "I had lots of feelings about it, but I didn't pay attention to them," and "I tried not to think about it." This seems consistent with the findings from focus group, which will be explored later in the findings. Children seem to have learned to suppress and/or ignore their feelings. Looking at the table again, the reader will also notice that the children did not score high on other questions that addressed their feelings about the war. For instance, children scored low on question number 14, "any reminder brought feelings about it." In addition, the majority of children (9 out of 11) scored "not at all" or "rarely" to question number 5, "I had strong feelings about it." The low scores on feeling related questions are evident. This seemed consistent with the children's responses in the focus group interviews. This will be discussed in detail in the following sections. However, it should be noted here that the way in which the children presented themselves came across as being tough young adults who were not bothered by their emotions. This tough facade somewhat changed after they became more comfortable in the interviews and after they were given the opportunity to express their thoughts and feelings. In summary, the majority of children scored high on the C R T E S , indicating a high degree of distress. The data also suggests that the suppression of feelings seemed to be common amongst the children. 62 Analysis Through Film In addition to the audio recordings, a digital video camera was used to capture the data for this study. The video was also used as a self-diary to process my thoughts and emotions as the journey into the war torn country unfolded. The camera was used to note my own observations. 1 also reflected on both the realities of war that I witnessed and on my own internal dynamic. M y previous memories of Mosul go back to my childhood - from fifteen years ago. I went to Iraq as researcher/observer who was returning to his hometown after the fall of Saddam's regime. However, I did not expect to experience the war personally and be touched by it. Living in a war environment feels surreal. It is a reality that is confusing. Everything about the war environment defies the concept of normalcy. It is an environment where patrolling troops aim their guns at you in your own neighborhood. It is an environment where the sounds of army helicopters awake you in the middle of the night, and continue to have an imposing presence during the day. It is an environment in which you are afraid of looking at the army helicopters or anyone wearing a military uniform. You may be mistaken for being an "insurgent" that is aiming an object at the occupying army, and hence be shot. The sounds of the helicopters also evoke a sense of disgust and resentment at feelings of lack of control. It is an environment where you find yourself suddenly frozen by the sounds of explosions or shootings. It is also an environment in which you can't count on the basic necessities of life. For instance, the Americans controlled the electricity in Mosul, which sporadically and unpredictably appeared for a couple of hours a day. Feelings of numbness, dullness and sadness seem to emerge in such an environment. By using the digital video camera, a film was made that captured these feelings, the dynamics that occurred in that war environment, and the situation in Iraq at the time. 63 The original intention was not to develop a documentary from all this material. However, the footage that was captured seemed compelling enough to be included as part of this thesis in a film documentary format. Hence, a film was made that captured the realities that I faced as a researcher, and the realities that the children of Iraq had lived through. The film weaves together the research material and the researcher's story. The title of the film is "The Other Reality." It provides another mode of analysis to the conventional thesis. The film highlights the emerging themes from the data and supplements the written martial that are provided. For further inquires on the film or to obtain a copy you can contact: • Kasim Al-Mashat, author. (E-mail at kal-mashat@shaw.ca) • Dr. Norm Amundson, thesis Supervisor from the University of British Columbia. (By phone 604-822-6757 or via e-mail norman.e.amundson@ubc.ca) The film was shown three times between February of 2004 and June of 2004. The number in the audience that attended the film ranged from 70 to 180 people. A l l three showings were held in Vancouver, British Columbia, Canada. Each showing of the film was followed by a question and answer period in which the researcher elaborated on his journey and the research findings. The first showing of the film was presented on February 26 at the 2004 Couch-Stone Symposium: Symbolic Interaction Crossing Boundaries. The conference was organized by the Society for the Study of Symbolic Interaction. The second showing was presented at Grace Vancouver Church. Grace Vancouver annually hosts a variety of cultural events that include a music night, an art gallery night, and a film night. The documentary was shown during their film night on May 28, 2004. The third showing was on June the 25, 2004 and it was also held at Grace Vancouver. The overwhelming positive response received from the majority of the 64 audiences has fueled further work on the film. The newly edited version of the film will be submitted to film festivals, and it will be shown again. Peer/Audience Response to the Film As a validity check for the findings presented in the film, a number of questions where asked of the audience. Specifically, written feedback was received from peers from the Department of Educational and Counseling Psychology, and Special Education from the University of British Columbia, Vancouver. Responses from seven peers were complied and highlights are presented below. The feedback that was received addressed five primary questions. Resonance. Peer respondents were asked if the film resonated with them in terms of knowledge on the subject of trauma. Some of the responses were: What I know about trauma was enforced and given depth by what I saw in the film....being an account of another world where different rules apply, where people live in greater fear and vulnerability, certainly resonates with my knowledge of traumatic settings. (Peer respondent # 1) Yes, the film resonated with my limited knowledge of trauma and nicely placed into a much more human context....it provided a such-needed 'real-life' viewpoint. I felt it portrayed best the lasting effects/residue of trauma. (Peer respondent # 2) Yes, the film did resonate with me in terms of knowledge on the subject of trauma....I heard an overwhelming 'mass of emotions' many of which seemed to me to be rather chaotic.. .and mixed in there a sense of numbness. (Peer respondent # 3) Living in the war situation has been totally unfamiliar to me....Therefore this film is a good reminder for me to know that those innocent children are greatly suffering from their painful experience related to war. (Peer respondent # 4) 65 Pragmatic Value. Peers were also asked if the film had implications for counselling psychology. They were asked if the film will affect their practice, and how they would treat someone who has experienced trauma differently after seeing the film. Responses included the following: Implications for counseling were very apparent in my opinion. I was astounded by how well complications concerning trust issues were conveyed....Likewise, how entrenched these feelings and anxiety can become throughout generations if left untreated. I feel this would be extremely helpful to remember when working with trauma victims, in order to understand the patience and time needed to build positive rapport, to understand environmental/familial influence, as well as to instill faith in humanity/sense of fairness back into the client. (Peer respondent # 2) Yes, I believe the film does have implications for counselling practice. I will have a better understanding of the effects of war, a more personal understanding... .The film made me more curious, more aware and ultimately more interested and concerned about the effects of war on children. (Peer respondent # 3) ...it reinforces that time is needed to process trauma and it is completely individual regarding the time that it would take each person to process. (Peer respondent # 5) The film had definite implications for counselling practice with children who live in war. Both in terms of information and knowledge about the process that children go through and effects on children. It is of obvious benefit for anyone who is working or will be working with children in war zones and children who escape from war zones as refugees. (Peer respondent # 6) ...it helped equip me personally by giving me a better understanding of what the cues and behaviors are for children who have experienced trauma. Kasim's own traumatic experience and the telling of it also increased my ability to empathize with the traumatic experience. (Peer respondent # 1) Coherence. Peers that watched the film were asked if the film was coherent, and whether they now understood the subject matter better after watching it. Peer audience responses included: I believe the film was coherent. Presented as almost a story-like plot, the prevalence of the issues gradually unfolded and one was able to understand in greater depth the situation at hand. (Peer respondent # 2) I do understand the subject matter better now that I've seen the film. (Peer respondent # 3) .. .the film was excellent for reminding me of the humanitarian impact of the war and increasing my personal relating to the victims of Iraq, both occupying military and the Iraqi people. (Peer respondent # 4) The film was like a well-written book. The story was developing very effectively from the prologue to the finale. (Peer respondent # 5) The film was made really clear with the use of themes. This made it very easy for the viewer to follow and [it was] captivating. (Peer respondent # 6) Compelling. Peers were also asked if the film was compelling and if it moved them. Some of the responses were: 67 The seriousness of trauma moved me; the scary reality of being in an unstable country with soldiers wielding weapons and the sounds of aircraft/sight of tanks impacted me in a way that just the verbal description could not. (Peer respondent # 1) This point was the strongest one in my opinion. What I found most moving was watching the change in you and your character as the events unfolded. To observe someone you know seemingly change before your eyes, was very impactful. (Peer respondent # 2) Absolutely. It moved me because it was you... .It also moved me because it was about a group of people that I know little about. To hear and see the faces stirred my heart with compassion and also — fear - fear for what these people face every day and fear for the impact on the future. (Peer respondent #3) The personal story....of you and your grandfather, were compelling....I was moved by the no-win situation for everyone involved in this conflict. The futility moved me as did your raw emotions on the screen for all to see. Your courage in sharing your experience so publicly as well the bravery and honest in embarking on the journey was also very moving. (Peer respondent # 4) There were several moments when I felt deeply sad....moments where children spoke about witnessing people get hurt, talking the language of war, the reality that some children have been exposed to war since birth and they don't know otherwise, the constant threat for the children. The ending was particularly compelling.. ..It seemed to give time to let the most striking images imprint in my mind and heart. (Peer respondent #6) 68 Contribution. Peers were also asked whether they thought this research contributes to trauma theory. Their responses included of the following: ...I think it richly illustrates children war survivors' experience of trauma, and also Kasim's own traumatic interrogation experience - it puts faces and reality to trauma theory, so it is no longer just a theory! (Peer respondent #1) .. .it makes a huge contribution in a very qualitative way concerning how to further understand the experience of the individual who has experienced trauma. It also hits home the idea that no one is immune from trauma and just how much of a block it can be to optimal functioning. (Peer respondent # 2) Yes, your research is so important to trauma theory! You speak from experience. You were close to the context in which the trauma occurred. You heard the voices directly. You were able to enter the participants' life world in a way that researchers who are listening from outside of the context can't do. To some degree you experienced with them - and so you can provide a richness of understanding that can help to expand what is already known. (Peer respondent # 3) Absolutely....we can expand our 'accuracy' 'range' and 'depth' of empathy....through careful observation and by listening to the stories of others as well as watching this kind of film. (Peer respondent # 5 ) Definitely. It provides a very up to date knowledge on children who are going through war today - the language of war, children who have always lived in war and don't know otherwise, support systems for children in a war zone. (Peer respondent # 6 ) In addition to the validity check provided by the peer audience responses to the film, this research also included an additional rigor check. A psychiatrist was interviewed in Mosul, who 69 verified and elaborated on the findings of this study. Segments of the interview are also shown in the film "The Other Reality." For the full transcript of the interview see Appendix D. Themes The focus group interviews addressed the research question of interest, "what were Iraqi children's experiences of 'Operation Iraqi Freedom' and what meaning did the war have for them given their cultural context." During the focus group interviews the children were given the choice to either elaborate on drawings they had made or to read letters they had written regarding their war experiences and the meaning it had for them. A number of themes emerged from analyzing the data. These themes will be highlighted next. But first, some comments and observations will be noted on the children's drawings. The children made eight drawings (see Appendix G). A l l eight drawings contained airplanes or helicopters. Six drawings showed missiles being dropped on either buildings or houses. There were also six drawings that contained children and/or adults who were being targeted or being fired upon. Four drawings also included either soldiers or tanks in them. Also of note, all of the six children that used colored crayons in their drawings used a red color. Red was used to color a number of items in the drawings: the victims, the cars that were hit, the building that were hit, the missiles that were falling, and red was used to highlight pools of blood. It seems that these children were reenacting their traumatic war experiences through their drawings. The children elaborated on these drawings as well as on the letters they wrote. The themes that have emerged from the analysis of the finding are provided next. Frightening War Stories. When the children expressed their thoughts and feelings around their war experiences, most of them shared frightening war stories. War to these children meant a number of things: killing, death, bombing, suffering, aggression, hostility, lack of security, 70 constant fears, and occupation. War to them also meant feeling like they were going to die. It meant being uncertain about the future, and having bad dreams at night. War to these children also meant being deprived of their daily routines and not being able to see their friends. In regards to the latter, the children expressed their anger at not being able to play outside with their friends as they used to. This was due to the lack of security and continual fighting in Mosul. The children also missed some of their friends who left their neighborhoods to other safer areas during to the war. The children shared what they had witnessed both during the war and after the official end of the war in May of 2003. They shared vivid and detailed memories regarding their experiences, which seemed traumatic. They described their experiences as being "harsh," "scary to death," and "frightening." Some of these experiences included the following: witnessing missile bombardment in and near their schools or homes; witnessing friends and classmates being hit by shrapnel; having freighting encounters with American soldiers and having guns pointed at them; witnessing civilians being shot; and seeing body parts and blood. Most children also seemed bothered by the sounds of the helicopters and planes, which were daily reminders of their frightening war experiences. This is also reflected in the majority of the children's drawings, which include helicopters and planes in them (see Appendix G). Language of war. One of the ways that children seemed to make sense of their war experiences was by thinking like "grown ups" and by their use of political ideology. The children spoke like they were adults. They were more inclined to talk about their political views of the war rather than their feelings around their experiences. They felt a strong sense of resentment and hatred towards the occupying army. 71 The children also spoke about wanting to fight the Americans. They wanted to kick the Americans out of the country. Three children hoped to fight and "die as martyrs." This was one of the most surprising finding to the questions "what are your hopes for the future," and "what would you want to be when you grow up?" Even though most children expressed a disliking for Saddam Hussein and his regime, they expressed a sense of humiliation at the actions of the occupying army. This seems to contribute to their hostile feelings towards the Americans. The children also seemed to have stopped dreaming or fantasying about future aspirations. One would expect children at their age to share future dreams, such as becoming a firefighter, a sports star, an artist, a doctor or any other aspirations. Instead, their most common response was their hope to fight the Americans and "die as martyrs." They also shared feelings of foreshorten future. Seven children expressed feeling that they were going to die. They also felt like they were not going make it through to the next day. A number of children also made sense of their experiences by identifying with Palestinian children. Four of the children felt that they would face similar struggles. They felt that they were going to continually live under an occupation and under both hostile and fearful conditions. They also expressed fears of losing their homes in similar ways that some Palestine families have. Some worried that they will be forced out of their homes and left homeless. It should be noted here that the struggles and courage of the Palestinian "stone throwing" children are generally culturally respected in Iraq. Therefore, the identification with Palestinian children seems to be a way that the children in this study made sense of some of their experiences. It seemed to give them a sense of pride in their own struggles. Children were also familiar with the names and functions of weaponry. They referred to these weapons in their drawings and discussions. The children seemed more familiar with 72 weaponry and the language of war than they were with some toys or computers. For instance, while one child was describing his favorite computer war game, he had difficulty naming the "joystick" and "mouse" that are used with such games. The children's interest in war games was also a dominant theme. For example, role-playing war games were popular amongst the children. In short, the children did not speak like they were children. They spoke like adults and expressed adult like thoughts and feelings. Thus, they spoke and enacted the language of war. Good equals tough. Another theme that emerged from the focus group interviews pertains to the way in which the children presented themselves. They indirectly conveyed the quality of toughness and came across as strong and brave young adults. This was conveyed through their mannerism, non-verbal communication, thoughts, and feelings. When first asked about their experiences, some children did not express any emotions while others expressed emotions in a detached way. After further probing, however, some did express their fears and elaborated on their feelings. The children seem to have learned to communicate in a tough facade. In other words, being afraid was perceived as a weakness that they did not want to reveal. They also seem to have learned to equate the qualities of being tough and unemotional with being a "good" person. In other words, a good person is one that is tough. As shown in the film "The Other Reality," one child dismissed the idea of being scared when an American soldier pointed a P K C machine gun at him. This was surprising since any adult would have been terrified if such a large weapon was pointed at him/her. This detachment from feelings was common amongst the children when they shared their stories. They spoke of their war experiences in a nonchalant way. In addition, when some of the children talked, they spoke more about their feelings instead of expressing them. In short, the children exhibited emotional detachment and conveyed a tough bravado. 73 Coping. A number of themes emerged in regards to how children coped with their war experiences. The tough bravado that the children expressed seemed to be a common coping mechanism. It seems to give them a sense of strength when feeling vulnerable. Another copying mechanism that the children used was staying close to their parents. One child reported that he no longer enjoyed playing alone in his room as he used to. Another child expressed her need for staying close to her parents. The children also shared the activities they engaged in to distract themselves from what was happening around them. Some of these activities were: listening to music, watching T V , hiding under their blankets and under their beds, reading books, doing homework, going to sleep even during the day, playing computer games, and trying to play with their friends or siblings. In addition, some children coped by watching the missile bombardments or explosions. Some went on the rooftops of their houses to watch what was happening. Also of note was the use of prayer as a copying mechanism. Prayer seemed to have played a vital role in helping the children to minimize their fears. They red passages from the Koran and prayed when they felt scared. This seemed to bring them comfort and strength. The use of prayer as a coping mechanism was consistent theme amongst the children, regardless of whether they seemed to show signs of minor or more severe post-traumatic like symptoms. Severity of traumatic symptoms and effects of war. From the observations made during the focus group interviews, a relation emerged between the severity of post-traumatic like symptoms and the severity of the child's traumatic war experience. This study did not use a measurement tool to assess this relation. However, by examining the data, it seems that the children who had the most obvious post-traumatic like symptoms where those that witnessed the most horrific and graphic events. For instance, one child shared his story of witnessing a man's head getting 74 decapitated by shrapnel during a missile bombardment (Participant # 7 from Focus Group 2). Some of the post-traumatic like symptoms that he shared were severe flashbacks, intense nightmares, and the physical manifestation of the symptoms such as vomiting and headaches. He also seemed to be the most anxious amongst the children. He had difficulty finishing his drawing, which he continually erased and redrew. He also asked the most questions during the administration of the C R T E S , and seemed the most anxious in filling it. The experience seems to have affected his self-esteem. He seems to view himself as a person who became ill or sick, and as someone who had an abnormal "severe psychological reaction," as he puts it. By observing him in the focus group, it is safe to suggest that there was a sense of vulnerability, as well as a fractured and broken sense of self that he seems to feel. The themes that have emerged in this study are also highlighted in the film. For further elaboration on these themes, refer to the film "The Other Reality." Here are some excerpts from the focus group interviews that touch on the above themes: .. .The sky was pouring with missiles rather than democracy. And children were dying from fear and from the cluster bombs that were dropped on us. Images and events I will never forget for the rest of my life. They deprived me from playing outside of my house, or even playing inside of my house if I am alone at home. When I sleep my dreams are filled with thoughts about the airplanes and air strikes and the war....During our playing, my friend died, and my other friend left town, so who can I play with? The missiles destroyed the amusement park, and they planted landmines on the ground, and the ground is filled with cluster bombs. Where do I play ? Answer me. Who is going to fight for our rights....1 pray to God to rid our beloved Iraq from all our enemies that have raped and occupied our country. (Participant #1, Focus Group 2) 75 ...Every Iraqi child could not sleep at night during the war because they were scared from missiles and the scary noises....I live in fear everyday when I go to school. I am scared of bullets that are randomly fired by the Americans....And about the future, what future is this? Are we going to have the same future as the occupied Palestine? The Iraqi child is left without a future....I was born in the war and I don't know how I well die. (Participant #2, Focus Group 2) ...I am not able to sleep at night, because I wonder if I will be able to see daylight again or will I die. The sound of air sirens startles me in the middle of my sleep.. ..I don't accept this war on my country. Iraq is my only homeland, and I don't have any other home. I love my country, and I am willing to sacrifice my life for it, and become a martyr for my homeland. (Participant #6, Focus Group 2) ...they had planes flying....[and] the strike happened. There was even a man on the top of the roof, his head was decapitated.... And my other friend...was hit by five shrapnel in his leg. It looked like Donair.. . .My face became red. I vomited the whole night and could not sleep....I remember terrifying nightmares....Sometimes still happens...The other day, at night. I could not sleep. I kept dreaming about him. M y dad kept on saying just open your eyes. I try to open my eyes, and read passages from the Koran. M y eyes are open, but I still dream about him. I am asleep but awake....It was like I was in the same place again....I also woke up in the morning with a headache and vomiting. (Participant # 7, Focus Group 2) 76 Chapter 5: Discussion This study examined the research question "what were Iraqi children's experiences of 'Operation Iraqi Freedom' and what meaning did the war have for them given their cultural context." Now that the research question has been addressed in detail and the emerging themes were examined, the focus will shift towards a discussion of these findings. This process will begin by exploring the fit of these findings with the existing literature in the field. This will serve as a final validity check for this study. Implication for research and counselling psychology will then be explored. Finally, this study will conclude by stating its limitations and by examining implications for future research. Fit with Literature A number of studies were cited that informed this research. Key studies and their fit with this research will be examined. But first, the findings will be examined in relation to the theoretical models on childhood trauma, which were explored in the literature review. Terr's (1991) theoretical model proposes that there are four primary characteristics that distinguish childhood trauma. The first characteristic that Terr describes is the child's experience of strongly visualized or repeated memories. Two children in this study reported having strongly visualized or repeated memories of traumatic events they had experienced. For instance, one child reported having memories and "visualizing and seeing" the civilian man that was shot dead in front of him by the occupying army. Another child reported having repeated memories of witnessing the decapitation of a man's head by shrapnel during a missile bombardment. The flashbacks that this child described were intense, and it made him feel like he was reliving his experience. 77 The strongly visualized or repeated memories of the children in this study also seem consistent with van der Kolk's (1996, 2002) theory on traumatic memories. He makes a distinction between ordinary memory and traumatic memories, which were also examined in the literature review of this study. If the two children discussed above were experiencing ordinary memories, they would not have relived the images and physical sensations that they felt during the event. According to van der Kolk, these children's traumatic memories have not been assimilated or integrated into their experience. This suggests that these children have not fully processed their traumatic experiences. The second characteristic of childhood trauma, according to Terr (1991), is that they engage in repetitive behavior or play reenactment of the trauma. Play therapy was not employed in this study, hence observations on repetitive play was not sought. However, observations were made on the children's drawings in the focus groups. They draw specific elements relating to the most traumatic event that they had experienced (see Appendix G for the children's drawings). The children also verbally expressed their desire to die as martyrs in the focus groups. In other words, the children did engage in the reenactment of their trauma through their drawings and discussions. The third characteristic of childhood trauma described by Terr is the child's experience of trauma specific fears. This characteristic was also consistent with the findings in this study. The children reported feeling scared and bothered every time they heard sounds of helicopters, military planes, explosions, or shootings. When they heard these sounds while playing outside they would stop and go indoors. The children in this study also reported being afraid of the dark and afraid of being alone. One child reported that he no longer enjoyed playing alone in his room because of his fears. Another child expressed a need to be close to her parents. The need 78 for maintaining parental attachment seems to have helped the children to cope with their traumatic war experiences. It seems to have reduced their fears while providing them with comfort and security. This is consistent with van der Kolk's notion that adolescent's attachment to family and peers is an important factor that contributes to their psychological well-being (van der Kolk, 1985; Streeck-Fischer & van der Kolk, 2000; van der Kolk & Fisler, 1994) The fourth characteristic of childhood trauma, according to Terr, is that children go through changes in attitudes about people, aspects of their lives, and their future. This fourth characteristic was strongly evident in the children that were interviewed, as it was explored in the findings section of this study. For instance, the children expressed feelings of foreshortened future and having thoughts of being martyrs as their primary hope for the future. The primary characteristics of childhood trauma described by Terr seemed evident in the children interviewed in this study. Therefore, it is safe to suggest that the children in Iraq were showing signs of childhood trauma as a result of their exposure to "Operation Iraqi Freedom" war. Even though the findings from this study were consistent with Terr's characteristics of childhood trauma, there are some characteristics that need to be added. There seems to be both ideological and religious beliefs that children incorporate in the process of meaning making of their experiences. This was the case with all the children. Their hopes for dying as martyrs and fighting to liberate their country from the occupiers seems to give them a sense of empowerment and control. After all, the war was imposed on them and they did not have a choice but to live through their war experiences. Thus, they seem to feel a sense of control over expressing their choice of fighting and dying for their country. 79 Dying as martyrs also has cultural and religious implications in Iraq. Dying fighting for your country and religion may raise you to a hero like status. By dying for a noble cause, your death will not be in vain. In fact, one child specifically expressed not wanting to die of just a "normal death". She wanted to die as martyr. Dying as a martyr has implications for being rewarded in the afterlife. It should be noted here that even though the children's thoughts and feelings about becoming martyrs were genuine and sincere, it did seem more of a coping mechanism. In other words, it seems unlikely that these children will act on their thoughts. Their thoughts around death may function as a tool that provides them with strength and allows them to express a sense of pride and control. It also allows them to make sense of their experiences by drawing on their cultural and religious beliefs. Terr (1991) also describes three types of reactions that follow childhood trauma. She describes reactions that fall under Type I, Type II, and a cross over manifestation of both types. These trauma reactions were also discussed in detail in the literature review of this study. As it was expected, the children in Iraq seemed to exhibit crossover reactions between Type I and Type II. This may be due to their repeated exposure to the war and violence in Mosul. For example, the children interviewed exhibited denial and psychic numbing to cope with their traumatic experiences, which is a Type II reaction. They also seemed withdrawn and distant during the focus group interviews. Some children also seemed to have misperceptions or time distortion, which is a characteristic of Type I reactions. For instance, when describing the event of witnessing the decapitation of a man's head during a missile bombardment, Participant # 7 from Focus Group # 2 seemed to switch between timelines of the event. He would describe how he felt during the event, but then refer to the event with a more recent time frame. 80 Misconceptions such as these also seem consistent with van der Kolk's theory (2002b) on the impact of trauma on the brain. According to van der Kolk, traumatic experiences seem to prevent trauma "imprints" from being organized into a narrative (p. 4). Instead, the trauma imprints seems to be stored as fragments. This was also evident in the letter that Participant # 7 wrote, which seemed choppy and his narrative did not flow. It should also be pointed out here that not all the children had reactions similar to Participant # 7. One way to account for the difference in the children's reactions is by looking at the intensity and magnitude of the traumatic event that they had experienced. Participants # 7 seemed to have experienced the most graphic and most disturbing traumatic event among the group. This suggests that the more severe the traumatic experience the more severe a child's reaction will be. There is another way to account for the differences between the intensity of the children's reactions. Briere (2002) suggests that not all children exposed to trauma develop significant post-traumatic symptoms. This may explain the variation in post-traumatic like symptoms exhibited by the children. Now that the findings were explored in relation to key theories in the field of trauma, the discussion will shift to an exploration of its fit with several key studies in the area. Dyregrov, Gupta, Gjestad, and Mukanoheli (2000) examined children's reactions to the genocide in Rwanda. They found through their multivariate analyses that the extent of exposure to violence was related to the degree of intrusive memories, thoughts, and arousal. Even though this study with Iraqi children did not set out to measure the relation between exposure and these variables, the findings were consistent with those of Dyregrov et al. Again, the Iraqi children in this study who shared the more violent and horrific experiences seemed to be the ones that had the most vivid memories and intrusive thoughts. Another finding that was consistent in both studies were 81 children's beliefs in their foreshortened future. Similar to the findings of Dyregrov et al., the majority of the children in this study (7 out of 12) believed that they were going to die during the war and also worried that they would not live to become adults. Both studies were also conducted at least three months after the traumatic event. This was important since according to the D S M IV-TR, the onset of PTSD is at least three months after the traumatic event (APA, 2000). Even though this study did not measure the presence of PTSD, results from the C R T E S revealed comparable levels of distress. More importantly, these finding were captured about seven months after the official end of the war in Iraq in May of 2003. In other words, similar to the findings of Dyregrov et al., time alone did not seem to alleviate the psychological symptoms of trauma experienced by the children interviewed in this study. There were other key studies that informed this research. Two studies that were discussed in the literature review specifically examined Iraqi children's experiences after the 1991 Persian Gulf War (Dyregrov, Gjestad, & Raundalen, 2002; International Study Team, 1991). Dyregrov et al. observed that many children interviewed had been left feeling alone with grief and distress. Some children's parents told them to forget their experiences. History seems to have repeated itself in Iraq. A n interview with an Iraqi Psychiatrist in Mosul revealed similar findings (see Appendix D for full transcript). Due to the distress that adults were feeling in Iraq, they seemed emotionally unavailable to help their children to express their thoughts and feelings about the war. This seems to have also left the children feeling alone with grief and distress. Dyregrov et al. also found that the majority of children reported experiencing irritability and concentration problems. The children in this study were not specifically asked about such difficulties. However, the interview with the Iraqi Psychiatrist indicated consistent findings. Children exposed to traumatic war experiences in Iraq did seem to have irritability and 82 concentrations problems. Another important finding from the Psychiatrist's interview was that post-traumatic symptoms in Iraqi children manifest themselves more behaviorally than emotionally. The most common diagnosable outcome of a child's exposure to traumatic war events, according to the Iraqi Psychiatrist, is Conduct Disorder. It seems that the Psychiatrist used the D S M IV criteria to note her observations. However, the behavioral manifestation of these children's traumatic experiences could be viewed as normal reactions to an abnormal event. War is an abnormal situation that could trigger children to behave in normally unacceptable ways. In other words, we need to be careful of not pathologizing the reactions of children who were exposed to war trauma. Dyregrov et al. also found that the majority of the children reported being unhappy (sometimes or always) at all three time points of the study. This unhappiness or sadness also seemed to characterize the children in this study. However, unlike the Dyregrov et al. study, two children reported that they felt happier now compared to the time of the war and the missile bombardments. It seems that the experience of living through missile bombardments was one of the most disturbing events for the children interviewed in this study. This also seems consistent the findings of Macksoud, Aber, and Lawrence (1996), where it was suggested that missile bombardments were amongst the top disturbing events that impacted Lebanese children. Berman's (1999) work was also key in informing this research. It informed this study on how children make sense of their war experiences. Findings from her work seem consistent with the findings in this study. Berman had found that the children spoke of happy times prior to their war experiences. The children in this study were also nostalgic and talked about better times prior to the war. For example, they shared memories of freely playing outside with their friends 83 without being afraid. The children in both studies also spoke in detail about the actual traumatic events they experienced. Berman also reported encouraging findings. The children in her study expressed optimism and a feeling of being "lucky" for surviving. This was somewhat similar to the Iraqi children interviewed in this study. They did express a feeling of gratitude for being alive. They shared how lucky they felt by saying that their survival was "an act of God," and "a miracle." Their gratitude incorporated their religious and cultural beliefs. However, they did not express a sense of optimism. They shared a sense pessimism and fear of the future. This may be a reflection of the uncertainty that was felt among Iraqis in general, where fighting had continually persisted. In addition, the children in Berman's study expressed that they would not be able to ever forget their experiences. Nevertheless, they did not express desires for revenge. Even though the Iraqi children in this study also expressed that they were not going to forget their experiences, they did share a strong desire for revenge against the occupying army. There are other differences between the two studies. The children in this study seemed to express feelings of envy for those that lived outside of Iraq. They spoke about stories they heard about living in a world that is safe, secure, and organized. The outside world seemed liked a sharp contrast to their reality, and seemed to like an unattainable safe haven for these children. The children that Berman interviewed did not seem to express such thoughts. Furthermore, the children in Berman's study did not understand the purpose of the fighting and the reasons for the war. The children in this study, on the other hand, seemed to be clear on the purpose of the fighting. This may suggest there were stronger political and ideological influences that seem to have shaped the meaning that children made of their war experiences in Iraq. 84 In summary, findings in this study seem consistent with the related literature in the field. This fit with the literature further contributes to the validity of the study. This study has also offered meaningful insight into the way that Iraqi children made sense of their war experiences. Particularly, this study demonstrated the importance of ideology, faith, and culture in how children make sense of their traumatic war experiences. Implications for Counselling Psychology Counsellors working with war traumatized children need to be aware of a number of issues. To work effectively with these children, counsellors or mental health professionals may need to learn about the war environment in which the child lived through. This may better equip them in understanding the specific situation of the children that they are working with. Most wars have commonalities in terms of their effects, such as the destruction they inflict, the chaos that emerges, the hardship that people live through, and the witnessing of brutalities. However, not all wars unfold in the same way. Counsellors need to ask questions and research the specific context of the war that the child lived through. Some of the questions that can be contemplated are: what parties were involved in the fighting; what were the weapons used; how close was the proximity of fighting to the civilian population; how long and how intense was the war; what were the living arrangements of the family during the war; what were the living conditions during and after the war; and, what were the ideologies, political and religious views of the parties involved in the fighting. By understanding the context in which the war occurred, counsellors may work more effectively with war-traumatized children. Counsellors also need to be aware of some of behaviors and coping mechanisms of war traumatized children. Specifically, children who experienced the war in Iraq seemed to have learned to suppress their feelings and project a sense of strength and toughness. This has 85 important implications for counselling psychology. But first, the factors that seemed to contribute to the tough bravado and emotional detachment exhibited by some of the children will be examined. The children may have learned this coping mechanism from their parents and other adults. The Iraqi culture seems to encourage the qualities of strength and bravery. Showing your emotions or expressing your fears may demonstrate a sign of weakness, which is not culturally encouraged. As presented in the findings, it seems that a good person is perceived as one that is tough. Secondly, the adults seemed to be emotionally drained, as mentioned earlier. This may have rendered them less emotionally available for their children. The adults seemed preoccupied, worrying about the day-to-day living and survival of their family. Thirdly, the children could have learned the qualities of strength and bravery from their siblings. Their older siblings had experienced the 1991 Persian Gulf War and the ensuing sanctions that followed. Exposure to these events and hardships could have further fostered the qualities of strength and bravery in them. The children could have learned these qualities from their older siblings and role models. Therefore, counsellors need to be aware that the tough bravado and emotional detachment exhibited by some children may be a learned coping mechanism. This has an important implication for counselling psychology. Children's tough bravado and emotional detachment may function as a way for masking some of the pain and vulnerability that they may feel. It may also function as a way to distance them from such pain. This was the case for both males and females in this study. War seems to override gender differences in how children make sense of their experiences. The tough bravado communicated by both genders seems to have allowed the children to talk about the death and injuries of their friends and loved ones in a detached way. A superficial or 86 rushed assessment of the children may erroneously indicate that their resilience has helped them to overcome their war related trauma. However, the tough bravado and emotional detachment may be signs that the children are still dealing with their traumatic war experiences. They may not have fully processed or integrated those experiences. Counsellors could play an important role in helping children to processes and integrate these traumatic memories. Counsellors working with children exposed to war trauma also need to be aware of some of the general feelings that may be triggered in such an environment. A sense of numbness, dullness, and sadness was observable in the children. These feelings may resemble some symptoms of depression. However, depression may only be a secondary diagnosis to PTSD. Counsellors need to be aware of the post-traumatic symptoms and feelings that may be triggered in a war environment to avoid the risk of misdiagnosis. There are also ethical implications in working with war-traumatized children. A child's tough bravado may mislead a counselor in thinking that the child is prepared to further explore their traumatic experiences. However, this may run the risk of prematurely pushing the child in the exploration of these experiences. This may prove to be harmful to the child. As seen in the film "The Other Reality," the vulnerability of children can quickly surface. For instance, one of the children interviewed spoke about her father who was half paralyzed as a result of the war. At first, the child seemed comfortable talking about her father, but when the questions continued she suddenly seemed on the verge of an emotional breakdown. At that time, she was given the opportunity to stop talking about the subject, and her feelings were normalized and validated. Therefore, war-traumatized children's tough bravado may give the impression that they are mentally and emotionally prepared to explore difficult issues, when in reality they may not be. 87 Counsellors need to be gentle and patient in the exploration of a child's traumatic experiences. Counsellors could also help the children by providing strategies for coping with the stress related to such explorations. For instance, breathing or relaxation techniques could be used to help a child when feeling overwhelmed in therapy. There are also implications pertaining to the development of therapeutic alliance with war-traumatized children. Trust may take longer to develop. In fact, disruption in trust is known to be a common consequence of people who experience PTSD (Marotta, 2000). This was evident in the children that were interviewed in this study. They seemed distant and cautious at first. What may have helped the process of trust building in this study was the self-disclosure that the children were provided with on the researcher's background. Counsellors working with children exposed to war trauma need to be patient and work diligently in building trust and therapeutic alliance, which may take time to establish. Trust and rapport building in this study seems to have been furthered by the procedures used. Specifically, the use of drawings and letter writing were unobtrusive ways that engaged the children in exploring the issues. By giving them the option to either draw or write a letter, they seemed to feel more comfortable in engaging in the process. Both of these tools also gave the children a sense of empowerment and control. In fact, the letters that the children wrote were surprisingly expressive, thoughtful, and touching. The drawings were also revealing and helped the children to elaborate on their experiences. It is recommended that these tools be used when working with war traumatized children. In summary, this study has raised a number of issues that have implications for counselling psychology. Counsellors may benefit from the findings and discussions of this study to assist 88 them in understanding the nature of war trauma, and to better equip them in working with children exposed to it. Implications for Conducting Research Conducting research in a war torn country has many implications. First, implications pertaining to the logistics of carrying out research in a war zone will be explored. As mentioned earlier, the very nature of war is unorganized and chaotic. From experience in conducing this study, it seemed that "Murphy's law" was alive and well in a war zone. In fact, the possibility of things going astray in such an environment seems to intensify. A researcher who is accustomed to rigidly following particular plans or procedures may face difficulties. Learning to be flexible and adaptive to unforeseen situations will prove to be paramount for the successful completion of research in a war torn country. This also means that a researcher needs to have multiple contingency plans for conducting their work, and be prepared to create new plans at the spur of the moment. The theme of flexibility and adaptation of the research characterized this study. The original plan was to work in conjunction with a non-profit organization in Iraq, such as UNICEF. The plan was to obtain assistance in conducting many aspects of the research in Baghdad, such as transportation of the participants and making arrangement for the location of the focus group venue. Plans were in the works months prior to going to Iraq. However, the deteriorating situation in Iraq led to the complete pull out of almost all relief agencies by December of 2003. Thus, changes had to be made to the research plan even before entering Iraq. The absence of such support coupled with increasingly deteriorating situation in and around Baghdad led to the exploration of conducting the research in another city in Iraq. As mentioned earlier, this led to the decision of conducting the research in the city of Mosul. 89 Researchers also need to be aware that the theme of flexibility and adaptation may stretch their selection procedures, as it did in this study. As it was mentioned earlier, the original plan was to recruit participants by posting flyers and placing advertisements in the neighborhoods of interest. This option was ineffective due to the situation in Iraq at the time. This led to the contingency plan of attempting to contact schools in Mosul to recruit participants. However, schools were not able to provide access to the children without an approval from the Ministry of Education, which was shut down and non-existent during the war. This led to the reliance on personal and family contacts to find children for the study. In short, researchers that are planning to conduct their work in a war torn country need to be flexible and adaptive in many aspects of their research including their selection procedures. There are also many logistical details that researchers need to explore prior to their trip to a war zone. Depending on the nature of the study, the researcher needs to prepare in advance all the material and equipment that may be needed. The likelihood of finding any of the needed material in a war torn country may be slim. Preparation for backup equipment and batteries may prove to be vital. After all, even if electricity is functional in a war zone, the voltage differences may render the equipment to be unusable without proper electrical adaptors. These details may seem trivial at first, but the researcher may only have a one-time chance to capture the data. There are no rooms for errors or equipment malfunctions. Thus, to minimize the unpredictability of conducting research in a war zone, advanced preparation may be crucial for the successful implementation of the research. Other implications for conducting research in a war torn country pertain to security and safety concerns. The researcher needs to be aware of the risks and threats involved in going to a war zone. One of the questions that a researcher needs to ask him/herself is "am I ready and 90 willing to die to for this cause?" This question may seem extreme, however, it was the reality that I was faced with prior to going to Iraq, and during my stay there. War is random, chaotic and unpredictable. Bullets do not distinguish between the body of the enemy and that of a researcher. As shown on the film "The Other Reality," my research in Iraq nearly cost me my life. I was a millisecond away from being shot by an American soldier for carrying a camera. I was also detained and interrogated by the American troops in a location that was described by a soldier as "the worst place to be in." This was the reality that I was faced with in conducing my research, and it is a reality that researchers need to be aware of. A complete reflection and exploration of the benefits and costs of conducting research in a war zone needs to be explored by researchers while contemplating such work. Researchers also need to be aware of and be open to the possibility that personal issues may be triggered by their trip to a war torn country. In an environment where one is faced with images of destruction and death, being personally impacted by the experience is almost inevitable. It is very likely that a researcher may experience an internal dynamic that was not expected. Researchers may also find themselves faced with the subject of their own mortality. Unprocessed grief and loss may also be triggered. Researchers that have not conducted work in a war zone may be surprised by the above comments. After all, we sometimes have the expectation of simply entering and exiting the lives of our participants while only engaging in the research tasks of observation and data collection. The reality of war, however, imposes itself on anyone living in it. Therefore, self-care becomes necessary for maintaining the well being of a researcher working in a war torn country. Keeping a journal or diary would be recommended to help process some of the thoughts and feelings that may arise in such an environment. 91 Other research implications pertain to the selection of research tools for data collection. Specifically, researchers need to be aware of cultural differences in the administration of a scale. The C R T E S was administered in this study. As mentioned earlier, the C R T E S was selected since it is a relatively short and time efficient tool for measuring children's level of distress. The administration of the scale normally takes 10 to 15 minutes. However, it took around 50 minutes for the scale to be administered in the focus groups. Unlike most of the children in North American, the children in Iraq were not accustomed to completing such research scales. Thus, researchers need to be aware of the cultural differences and the unfamiliarity of such tools when planning their study. This may affect time allocation that researchers will need to plan for. Lastly, there are ethical considerations in conducing research with children exposed to war trauma. The purpose of the study was to collect data on children's experiences of the war. This meant using interview techniques to draw out their experiences in a safe environment. The delicate balance between seeking information and pushing the children too far is a reality that researchers may face. The researcher may feel an adrenaline rush when a child begins to share stories that address the research questions at hand. There may be a risk of wanting to push the child even further to "dig deeper" into the story. Being purely inquisitive without having the child's own psychological well being in mind may be unethical. Therefore, researchers need to be aware of this ethical consideration when conducting research interviews with children exposed to war trauma. It is also advisable for researchers who are planning to work with war-traumatized children to obtain specific training in the trauma field. This will better equip the researcher for working with these children. In doing so, the researcher can be more sensitive to the children's needs and be more skilled at dealing with any difficult situations that may be arise, such as child being emotionally triggered by the discussions. 92 Limitations Even though this research provides rich and meaningful findings on children's experiences of the war in Iraq, there are some limitations to the study. Convenience sampling was used. Participants were found through personal contacts and through a Psychiatrist in Mosul, who helped to locate children living in her neighborhood. This may raise the question of having some bias in the findings. However, the children were genuine and sincere in their reporting. This was apparent in the findings of this study. In fact, the consistency of the finding with existing literature further illustrated the validity of this research. Another possible limitation in this study pertains to one of the validity checks that were put in place. One of the procedures was to provide the participants with copies of the transcripts and findings from this study. This would have allowed for further confirmation on the trustworthiness and accuracy of the results. The procedure called for the mail out of the results to the participants in Iraq. The participants would have then returned their feedback to the researcher in Canada by an enclosed envelope, with prepaid postage. This procedure proved to be unfeasible and unattainable due to the escalating situation in Iraq and to the lack of postal service in the country. However, all of the other procedures were followed to ensure the validity, accuracy, and trustworthiness of the findings. Some of these procedures were: use of the researcher's journal entries; use of the researcher's observation notes made during the focus groups; summarization of the children's comments during the interviews and asking for clarifications; translating and transcribing the interviews by using both audio and video tapes of the focus groups; and the verification of the focus group findings by an Iraqi Psychiatrist in Mosul. 93 A third limitation in this study pertains to the possible exposure of children to previous trauma. This study did not investigate the link between previous trauma and the children's most recent traumatic war experiences. Investigating such a connection was not the intention of the research, and it was beyond the scope of this study. Even a surface exploration of this topic would not have been feasible. This would have required for an individual investigation with each participant regarding prior traumatic experiences. Given time constraints and security concerns in revisiting the participants, such an exploration was not conducted. Previous exposure to traumatic events may or may not have affected the meaning that children made of their experiences. After all, the findings from this study were consistent with the existing literature in the field. The qualitative nature of this study employs focus group interviews that are intended to gain in-depth insight into children's war experiences. The findings of this study are not intended for generalization. This study is not claiming that children in all war torn countries will have similar reactions and experiences. Instead, the concept of transferability is offered. Kruger et al. (2000) elaborate on this concept by stating that it is "parallel to the positivistic concept of generalizability, except that it is the receiver (not the sender or researcher) who decides if the results can be applied to the next situation" (p. 203). Therefore, those who seek to use the results of this study will need to carefully look over this research to determine if the findings apply to their situation. This can be done by looking over a number of elements in the study such as: the procedures; the conditions under which the study was conducted; the methods used; the situation in Iraq at the time; the mode of analysis; and the type of questions asked. In other words, as Kruger el al. have suggested, what may be transferred are the larger theoretical concepts instead of specific findings. 94 Future Research Future research in this area could address several issues. Future research could explore age differences in children's psychological reactions to war trauma. Such research could explore the differences in cognitions and meaning making of children from two developmentally different groups, such as a group of 8 year olds and a group of 13 year olds. Developmental considerations and comparisons may provide further insight into children's war experiences and the meaning it has for them. As indicated earlier, exposure to previous traumatic experiences may affect a child's reaction and meaning making of his/her recent traumatic war experience. Future research could explore this connection. For instance, a future study could explore the meaning making of two groups of children exposed to the same traumatic war event. One group could consist of children that have no history of prior trauma, while the second group could consist of children with previous childhood trauma. A study of this kind could shed light on the connection between exposures to previous trauma and how children make sense of their recent war experiences. The study aimed to provide the participants with the opportunity to voice their experiences. The meaning making of the children's war experiences was mainly examined through their perspective. Future research could also include parents, teachers and relatives. Interviews with such adults may shed light on aspects of the children's reactions and experiences that the children may not have addressed. Observations made by adults may provide further information on changes in the children's behaviors, attitudes, and emotions following a traumatic war event. This may also shed light on changes in social interactions, changes in school performance, or changes in peer play. 95 Future research could also incorporate observations made on children's play. Particularly, observations on play or behavior reenactment may be beneficial. After all, repetitive behavior or play reenactment, according to Terr's (1991), is a primary characteristic of childhood trauma. Children could be provided with specific toys, such as silly putty, to observe their play. Observing children playing with their peers in a natural setting could also capture potentially valuable data. Finally, future research could also investigate the use of traditional healing in Iraq for treating war traumatized children. The interview with the Iraqi Psychiatrist briefly touched on this subject. It seems that there is a growing belief, amongst a small group of poor and less educated people in Iraq, that post-traumatic symptoms are induced by "bad" spirits that enter the child. Religious healers are used in such situations to cleanse the child and rid him/her of the bad spirits. Future researcher could investigate the use of religious healers in treating some trauma victims in Iraq. As for this researcher and Iraqi native, this study has provided opportunities for growth and self-exploration. The journey back to Iraq has touched me as researcher, as an observer, and as a human being. 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P. (1991). Child, adolescent, and adult victims of residential fire. Behavior Modification, 139L 560-580. Jones, R. T., Ribbe, D. P., & Cunningham, P. (1994). Psychosocial correlates of fire disaster among children and adolescents. Journal of Traumatic Stress, 7, 117-122. Jones, R. T., Ribbe, D. P., Cunningham, P. B., & Weddle, D. (1993). Predictors of child and adolescent functioning following trauma-related events. Paper presented in symposium entitled Children's Responses to Natural Disaster. Presented at the 101st Annual American Psychological Association Convention, Toronto, Ontario, Canada. Kennedy, C , Kools, S., & Krueger, R. (2001). Methodological considerations in children's focus groups. Nursing Research, 50 (3), 184-187. Kocijan-Hercigonja, D. (1999). Children in war. In Ullmann, E . , & Hilweg, W., Childhood trauma: separation, abuse and war (pp. 157-172). Aldershot, U K : Ashgate Kleinman, A . (1995). Writing in the margin: discourse between anthropology and medicine. Los Angeles, C A : University of California Press. Kleinman, A . (1987). The role of culture in cross-cultural research on illness. British Journal of Psychiatry, 151, 447-454. Kleinman, A (1987b). Culture and clinical reality: commentary on culture bound syndromes and international disease classifications. Culture, Medicine, and Psychiatry, 11, 49-52. 99 Krueger, R.A. , & Casey M . A . (2000). Focus group: a practical guide for applied research. London: Sage Publishing. Kuterovac-Jagodic, G . (2003). Posttraumatic stress symptoms in Croatian children exposed to war: a prospective study. Journal of Clinical Psychology, 59 (I), 9-25. Macleod, I., & Greenaway, N . (2003, March 20 th). Saddam defiant as cruise missiles hit capital. The Vancouver Sun, A1-A2. Marotta, S.A. (2000). Best practices for counselors who treat posttraumatic stress disorder. Journal of Counseling and Development, 78, 492-495. Marcella, A .J . , & White, G . M . (Ed.). (1982). 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Social Science and Medicine, 48, 1449-1462. Sundelin-Wahlesten, A . A . , & Knorring A . L . (2001). Traumatic experiences and post traumatic stress reactions in children from Kurdistan and Sweden. Academic Pediatrics, 90, 563-568. Terr, L . C . (1991). Childhood traumas: an outline and overview. American Journal of Psychiatry, 148(1), 10-20. Terr. L . C . (1981). Psychic trauma in children: observations following the Chowchilla school-bus kidnapping. American Journal of Psychiatry, 138(1), 14-19. Terr. L . C . (1983). Chowchilla revisited: the effects of psychic trauma four years after a school-bus kidnapping. American Journal of Psychiatry, 140 (12), 1543-1550. Thabet. A . A . (1999). Post-traumatic reactions in children of war. Journal of Child Psychiatry, 40 (3), 385-391. Ullmann, E . , & Hilweg, W. (1999). Childhood trauma: separation, abuse and war. Aldershot, U K : Ashgate. 101 United Nations Press Release. (2003, April 9 ). High Commissioner for Human Rights deeply disturbed by killing of civilians andjournalist in Iraq conflict. Retrieved May the 10th, 2003, from http://\VAVw.unhchr.ch/huricane/huricane.nsf/NewsRoom?OpenFrameSet Veltkamps, L .J . , & Miller, T.W. (1994). Clinical handbook of child abuse and neglect. Madison, Connecticut: International Universites Press. van der Kolk, B. A . (2002). In Terror's grip: healing the ravages of trauma. Cerebrum, 4, 34-50. N Y : The Dana Foundation. Retrieved June the 6 t h, 2003, from http://www.traumacenter.org/webarticles.html van der Kok, B .A . (2002b). Beyond the talking cure: somatic experience, subcortical imprints and the treatment of trauma. In Shapiro, F. E M D R : promises for a paradigm shift. N Y : A P A Press. van der Kolk, B .A . (1996). The body keeps the score. In van der Kolk, B .A . , McFarlane, A . C , and Weisaeth (Ed.). Traumatic Stress: the effects of overwhelming experience on mind, body and society (pp. 214-241). New York: Guilford Press. van der Kolk, B .A . (1996b). The complexity of adaptation to trauma. In van der Kolk, B .A . , McFarlane, A . C , and Weisaeth (Ed.). Traumatic Stress: the effects of overwhelming experience on mind, body and society (pp. 184-211). New York: Guilford Press. van der Kok, B.A. , and Fisler, R .E . (1994). Childhood abuse and neglect and loss of self-regulation. Bulletin of the Menniger Clinic, 58 (2), 145-169. Webb, N.B. (Ed.). (1991). Play therapy with children in crisis: a casebook for practitioners. N Y : The Guilford Press. Young, A . (1995). The harmony of illusions: inventing post-traumatic stress disorder. Princeton, New Jersey: Princeton University Press. Appendix A : Children's Reaction to Traumatic Events Scale (English) 103 Child's Reactions to Traumatic Events Scale (CRTES) JONES, R.T. (1994) Name: Date: Recently you experienced Below is a list of comments made by people after stressful life events. Please check each item, indicating how often these comments were true for you DURING THE PAST SEVEN DAYS. If they did not occur during that time, please mark the "Not at all" column. Not at all Rarely Sometimes Often 1. I thought about it when I didn't mean to. 2. I stopped letting myself get upset when I thought about it or was reminded of it. 3. I tried not to remember. 4. I had trouble falling asleep or staying asleep because pictures or thoughts about it came into my mind. 5. I had strong feelings about it. 6. I had dreams about it. 7. I stayed away from things that reminded me of it. 8. I felt that it did not happen or that is was make-believe. 9. I tried not to talk about it. 10.1 kept seeing it over and over in my mind. 11. Other things kept making me think about it. 12. I had lots of feelings about it, but I didn't pay attention to them. 13. I tried not to think about it. 14. Any reminder brought back feelings about it. 15. I don't have feelings about it anymore. | | | Appendix B: Children's Reaction to Traumatic Events Scale (Arabic) 105 A i l i a J ! * . \ ^ \ \ JiLlI Jxi JJ^J (jAjla (1994) ^ 4 J 4 jj A J J J A J A U i f r La : j j U i l : ? -VI ^ AAJ C h . S j j i t y J ^ U A J U l l t i l l J U J I 4 - . . ^ ^1 ^ 1 4 « £ U J I J ^ u . iL$jjlja.j (_ijaJLi (JjjSa Oil —1 j l jy-a <—UJUUJ Lulj j l _ji3l y& ' " • ~M Sy> £J&~4 . j j CJJS Sal -6 . <_JjaJI ilul jaj 106 Lib liiil j a j j l j£al ^ I W I CLulS (_$ j i J *Lui1 fc&iA - 1 1 C J ^ J J (^ 1 tiij-la. .lit i_j^ >aJl i^ j ^ l J ^ J t_gjjxA ^^jiui l I ' I ' I ^ ~ 1 4 Appendix C: Consent Form T H E U N I V E R S I T Y O F B R I T I S H C O L U M B I A 110 U B C Department of Educational and Counselling Psychology, and Special Education Faculty of Education 2125 Main Mall Vancouver, B.C. Canada V6T 1Z4 Main Office Tel: (604) 822-8229 Fax: (604) 822-3302 Program Areas Special Education School Psychology Measurement, Evaluation & Research Methodology Human Learning, Development, & Instruction Counselling Psychology Tel: (604) 822-5259 Fax: (604) 822-2328 Contact for information about the rights of research participant: If you have any concerns about your treatment or rights as a research participant, you may contact the Research Subject Information Line in the U B C Office of Research Services at 604-822-8598. Consent: Your participation in this study is entirely voluntary. You may refuse to participate or withdraw from the study at any time without jeopardy to your safety nor any jeopardy to access services from the community. Your signature indicates that you consent to participate in this study. By signing below you also acknowledge you have read and understood this consent form, and been provided a copy of this consent form. I consent/I do not consent (circle one) to my child's participation in this study. I assent/I do not assent (circle one) with my parent's consent to participate in this study. Parent or Guardian Signature Date Signature of the Child Date Signature of a Witness Date Appendix D: Iraqi Psychiatrist's Interview Transcript 112 Interviewer : Well, I want to thank you for your time. Interviewee: Ok. Interviewer : If you can tell me a little bit about your background and your clinical experience. Interviewee : You welcome. My name is Ilham . I am a consultant Psychiatrist. I work in medical education in the University of Mousel. I used to be the dean of the university clinic for two years. M y interest is community psychiatry. Interviewer: Community Psychiatry. Interviewee : Yea and I am specialist since 1983. So, I faced with different problems of children in different occasion. That is from 1980 to 1988 war with Iran. 1991 with.. Interviewer : Gulf war . Interviewee : Gulf war, and this war. So we saw a lot of children suffering. Interviewer: Yes. Interviewee : During these, you can say 22 to 23 years. Interviewee : In addition there is another thing that, thirteen years of sanctions Interviewer: Yes. Interviewee : Which's mean mal - nourishment, a lot of prohibition of everything, all activities with children and it mean that they are not living their childhood. Interviewer: Yes. Interviewee : So they the only thing that they think is the war and the consequence's of war and the deaths. Interviewer: Death. Interviewee : That affect the mother and father because of war the father is far a way. Interviewer : Father fighting the war. Interviewee : Fighting. And the mother is over worked at home, so that there is no childhood, no care, indoors, outdoors and the society . Interviewer: Yes . Interviewee : That's why we see the children are completely different from or our childhood. Interviewer: Yes. Interviewee : The only thing they think of where or when we are going to see peace to live in peace to go and travel. Most of the children they never fly. Interviewer: Travel. Interviewee : Yes, they don't know how to travel by an airplane or . . . so they feel that when they see T V films, they think that all people are living but they are not living their normal life. Interviewer : So, if they feel that they missed out Interviewee : Missed a lot, so , you can say that if we are going to talk about this war. 113 Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Yes . That the last war . Over throwing the regime . Yes, that we are talking about children, who passed through, about 10 to 13 years of age. Yes That's mean that all these children are they suffered from the 13 years of sanctions, in addition, they were traumatized by war . The current war that happened. Yes, so they, in the last 13 year they never had the proper food, the proper dresses, they used, things to play with or to travel or to see anything , in addition, they were traumatized by the war. So it is a big trauma for them. Interviewer: Interviewer: Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewee Interviewer: Interviewer: Interviewee So multiple trauma Yes, in addition to this trauma. So you can see when you talk to children properly the things you just see with these children, you feel that they are grown up. They do not speak about their childhood , they speak as if they are father or mother talking . They speak like adults. Adults, not like a child to talk about their play or their hobbies or... so you see completely different type of child. What I mean there is no childhood. So their frame of mind is as if they are adults and they are thinking about the suffering and how difficult life is instead of what to play. Yes , even when they play, they don't have any thing to play with apart than pistols, guns and things used during wars. They know every thing about airplanes , about guns and they do know about say they know some thing about say, they know something about computer, but they know every thing about war. So, these people know the language of war. Yes And they know the language of war more than regular life. Yes that's their usual life. During the war it was really as any war, all bombing. With listening to the news saying that that a lot of bombs a lot of, whether Uranium using or different types of bombs that has been been used by the Americans . "Yes". And a lot of killing. so, all the fear is there and the moment they see or hear any loud sound they go and hide anywhere, shouting and trembling and crying. That's the immediate '. Symptoms Symptoms and effect of war, and the moment the noises finish they can go out. They and never leave home, they never leave the family or the parent. They go you see out to play. Auho To see children and their friends. 114 Interviewer: Interviewee Interviewee Interviewer: Interviewee Interviewer: Interviewer: Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: They don't' feel safe going out. Yes not safe, up till now even Mousatfa, when I ask him go and bring me something from the next room. That's your son?". "Yes, he is Mustafa". Yes, When I ask him to go and bring me some thing from the next room he says I am afraid someone should come with me. He is frightened. He was not frightened before the war happened. He always, his life he was born in 1992. When the sanctions was there, there was no electricity, there was no water most of the time, a lot of things. So, in the dim light he cannot go out always we use gas if there is no gas or petrol. "Yes ". Always of thinking of this light, and food. Basic necessities ". That it, the basic necessity and always not there , so we don't talk about them , we are very tense when we come home and very tired from what we have seen outside, so when they ask us to discuss some thing with them and we feel that we can not cant answer them because we are busy thinking that we have to bring, water, light, things. Which is a basic necessity. We should not think of it, it is our A B C of life. So it is taken a away from the care that you cant provide children? Yes, we couldn't provide because we are busy. Their father work with, instead of one job he is start doing over time, and the mother star going out working looking for job to get money. To survive. So the children is the sufferer. A l l the time the children are sufferer. They pay the price, they pay the price. Yes. What have you seen or what meaning are these children making of war? what is it mean for them to be in war ? how do they make sense of it. War means aggression , it means fear, it means suffering, it means poverty, it means bad life, bad social life, so they feel that whenever there is war it means that there is aggression between two people; that's the enemy and our people. Someone is going to die. Someone is going to suffer as a result of that, so a lot of expenses, we know that we are now in a war ". Yes. And we hope that everything is finished, but we are sure that we will pay back. A l l the expenses that has been spent. Killing. We don't say kill you and kiss, kiss you and kill you. Yes. So they think that they are giving the something now but they are killing us now by taking all, draining all of our property out. The resources. 115 Interviewee Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewee Interviewee Interviewer Al l the oil, and all resources. To pay off all these our — " . Yes, we know that. That's why we feel its that, it is the children fell that it is means to them aggression, it means bad life, it means fear all the time, it means unsafely. Yes, what kind of symptoms are you seeing from your work, also as a mother, on... You can say that the symptoms that the family bring the child or the mother come to consult. Yes. Either director indirect. Yes. The mother will suffer from over burden because of the children and they are very hostile and hyper active always, shouting. She came in very nervous consulting the doctor to get relief. Or if the child is very destructive they will bring him or if they are they suffering from all the thing like depression, anxiety, fear, or toilet training problems, or hyper activity or some of the somatic symptomatic related to, like, abdominal pain. Headache. Or stomach. Or epilepsy, yes. A lot of these things, but mainly, it is conduct disorder they present from them rather than emotional, so probably number one conduct disorder. Number two is emotional. Because emotional, all of us are unhappy depressed. They don't take care to it. But the conduct disorder is disturbing others so they bring them for treatment. So, everybody's emotions are drained. Yes. And so the children don't have room to express those. That is true And the only thing that shows up is behavior . Yes, probably you have noticed it. That is all of them they are frightened and anxious and yes. They the don't mind that. You know, they didn't tell their family about it. Yes. And the families. Don't ask. They never consult the doctor for it. Yes. But if they fail in the exam or they have poor concentration or they have hyper activity they will bring them. They would bring it. And is that the things that you seen. You mentioned before, sleep or lost of appetite. Yes. Sleep, yes, yes, sleep or disorder of appetite or, as I said soiling problem. In addition to that to that, as I said, thirteen years of sanction affected the pregnant mother. Malnutrition and trauma as result of overburden. Yes. 116 Interviewee : So, a lot of mental retard. Or say, Interviewer: Delayed. Interviewee : Speech delayed or problem in their concentration or in their comprehension or intelligence, a lot of problems in that. As a result of the sanction rather than the fear of something. Interviewee : The fear. Interviewee : That is why, you see about, I can say, about ten percent of the children they consult with me with me with mental retardation, and about twenty as a result of the war in the last three months. Interviewer : I see, talk about twenty percent. Interviewee : Twenty as a result of war directly they say. Because either they saw the bombing. Interviewer: Yes. Interviewee : Or because they see saw someone killed, or because they saw some soldier try fight in there. Interviewer : Fight some body. Interviewee : Try to fight near here. Interviewer : How does it affect them? What impact does it have on those twenty percent. Or children from neighbors or children you know, how does it effect them. Interviewee : The treat it by social withdrawal, they try to stay alone or indoor. Don't communicate. They refuse to go to the school, that's why that affect their school a lot of, say , school problems emerge. Interviewer : Come out yes. Interviewee : That's if the family is well educated, if the family is not educated. They will say oh yeah, I don't mind, let my baby go and work and get me something. Interviewer: Yes. Interviewee : So, they go and sell cigarettes or sell something or some of them they are very bad families, and the will go to steal. Interviewer: To survive. Interviewee: Yes. Interviewee : But, those they don't come, because that they think, the family thinks that this is the normal thing they do. Interviewer: Typical. Interviewee : Yes, this is typical for them , but the educated family they come. Asking for help if there is poor schooling. Or school problems. Interviewer : They try to address it. Interviewee : Yes. Interviewer : How much cultural variations in PTSD like symptoms or stress?. Interviewee : Yes as I said, they don't come with the emotional aspect of it. Interviewer: O K . Interviewee : They come with the conduct problem. Interviewer: Related to. Interviewee : Related or the behavior, this is number one. And number two, they, you see a lot of religious beliefs came out. Interviewer: Yes. 117 Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Say that, I don't know how to it emerged. Whether it is also the sanction that people becoming poorer and poorer. They don't have the money to pay for consultation or drugs, or something like that. Oh, Ok.. So, they find it better if you are anxious or tense, or your child have sleep disorder, take them to the religious healer. So traditional healers. Yes, traditional healer, so this is something come out during this period. What does a traditional healer do? Some of them, if they are very, you see they religious people, they just speak, talk something from Qura'n. Yes, just do some readings from the Qura'n. Just some readings from the Qura'n.. Other, who are, I think ahh, I don't know what you say. Extreme. Or uneducated. Uneducated , they try to do a lot of things like getting blood or hitting them, so that Ginny will come out or. So the spirits, the bad spirit. Yes, yes or they . or making pressure on their eyes so the Ginny will come out. Or using electricity. Oh, so to get rid of the bad soul the bad. Yes to get out. So, a lot of them they are, I have one lady that was suffering from, say she was 15 years of age and she had the fever. When they brought her to me I said this is meningitis you have to take her to the hospital immediately. Next neighbor told them, no this is a Ginny or something. They went to a healer. Then they make a wound here (pointing across her mouth), and the second day she has emphysema and she dies. She died as a result of that, yea. So a lot of problem come out or from hitting them, they had broken bones So they try to hit them to get the spirits out. The bad spirits. (Next 1-2 seconds impossible to understand) So this is came out. And the photograph I saw you. The baby he was born, burned because the healer told her told the mother that you can get rid of the Ginny by burning it by hot water. Burning the babies. Burning the Ginny by hot water. So she took her to the bathroom, and put hot water. Then, she lost a lot of, she was about to die from the from the burn she had. So these are. Some of the variations. Yes, the main thing we notice, otherwise the same symptoms related to the religion. Aggression is and hostility. It is biggest. Because as I said, even the if the child was born in 1991. And his older brother or sister, they were born in the previous war. So say twenty to twenty five years. Al l they have in the experience of wars. So the figure or all the, say, all the family or all the brother and sister, they have the habit of treating each other by aggression and tension and 118 Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Interviewee Interviewer: Aggression and toughness. And toughness. Because the brave person who should be fighting or should be. You have to strong and aggressive. That is why all the stigma. You have to be tough You have to be tough to be good. A good person is a.. Tough person. Tough person So, you don't show your emotions. Yes, no emotions. Yes. Last two questions, how are children coping. What do they do to cope with their war experiences.? As I said, they can make with their peers alone, they can make play, either indoors or very near to their homes or they start, as I said educated one. They start reading or to play with toys to stay indoors and they play together. Even during a strike or during a raid or do they do to cope with their fears. Oh, they have to hide, just pray. Just to pray. Pray. Nothing more or just come for the family assurance. So they pray, like how do they do that. Just saying their prayers. A l l the time they hear it. And . . . So prayers, special prayers. Special prayers. Just praying God. Saying make it better, or help me to face it or something like that, and Another power outage. Very typical. Last question. What's from your experience or from your clinical experience, or your children or from your neighbors, what kind of hopes do these children have our outlook for the future. Really, the main hope for the children and for us is to live in peace. We can not cope with any more of wars and there hope is that to go and travel. To go and say play as usual children, to travel, to eat wherever they would like to. To do things. To do things. To spend their holidays. Do normal things. Normal things, that is it. Live as other people are living outside like people in North America and other. Just to live. We have the money but we want it spend it right, not on pistols and guns. On positive aspects. Excellent. Well, thank you for your time No problem. We hope that everything is okay and wish you the best success. I appreciate it, thank you. Appendix E: Demographic Information Question Sheet (English) 1. Name: Demographic information 120 2. Age: 3. Gender (male/female). 4. Grade: 5. Employment of working parent: 6. Number of siblings: 7. Did your family the experience the loss of one of its members during the war 8. Did any one from your immediate family, relatives, or friends get hurt as a result from war? If yes, then please list them: 9. Did your family relocate or move temporarily to a more secure location? If yes, then how long did you stay away? Name: Appendix F: Demographic Information Question Sheet (Arabic) 122 — V l j «ll :( Jut/ jSi) o - ^ l l claJI ^ L» c ^  uljaJI (jl£ IJIj ? l iU JSI >J (jjaJI J3Li 4£l*JI .'iffnl J A A P P E N D I X G : The Children's Drawings C2> 

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