The implemented TRT was run as an extra-curriculum, 16-session intervention. It enabled children to communicate troubling experiences with each other and sought to prevent feelings of isolation. It was helpful to know that others also felt helpless and dreadful, and that it was not always conceivable to tolerate extreme conditions of life threat. Furthermore, the TRT intervention was implemented to suit the needs of war-affected children who exhibited short attention spans and to highlight the culturally-pertinent aspects such as representation and dream work. Similarly, the findings confirmed significant direct associations between ER strategies and children’s various symptoms and well-being.
Moreover, our findings revealed that children responded in multiple ways to protect their mental health and maintain emotional balance.
However, the study deserves criticisms for the following reasons: First, the intervention may not have fully considered the conflicts and violence that children experience in the aftermath of major losses and destruction and the on-going trauma exposure and siege.
In an atmosphere of the ongoing trauma that exists in Gaza, it is difficult to find safety.
The presence of drones, frequent destruction of buildings, and the continuous threat of traumatic and violent death make the possibility of a safe haven remote. Therefore, it is essential to recognize this trauma threat as it exists even during an intervention and that a participant may not feel safe at any time. Alternately, the intervention with children could have been provided in a safer environment away from trauma reminders.
Second, the intervention can be criticized for partial reliance on community resources or collective coping capacities, which are supported by research (Kieling et al., 2011; Ungar, 2013). However, the involvement of children’s families in the intervention was a successful attempt in that direction. In the Gaza Strip, family groups are extensive and symbolize safe haven and offer “belonging” and consolation. Also, “El Hamula” (the extended family) protects and obligates family members to provide care for significant others.
Third, we did not test whether the amount of trauma or other social factors moderated the intervention effects and cannot, therefore, make further inferences about their relative importance. Accordingly, psychosocial interventions for war-affected children must be explicitly designed to invite, maintain, and enhance positive relations with their culture and faith. These strengths for the people of Gaza can modulate excessive fears, loneliness, and insecurity. Further, incorporating resilience-based aspects (i.e. family support and community support) would have enhanced the resilience of children and provided them with more coping strategies to overcome difficulty and empower them to function more fully.
Fourth, the psychosocial intervention was school-based; the intervention involved peers, but not caregivers, who are the main source of a child’s protection. In conditions of war (or ongoing threat of war) provision of support by the extended family structure is critical for the health or healing of a child. To strengthen the intervention, sessions involving family
groups could make the process emotionally safer and deepen the possibility of success.
Further, children who have been traumatized need family support and when family is involved in the sessions, the likelihood of success is higher because the family group can support the process and the outcomes. Conversely, if the intervention involves the child only, he/she returns to a family who may still be traumatized and may not be able to understand or support the intervention. A family that is involved in the intervention, may be better able to understand the child’s behavior and support the plan for working with the child’s anger and fears.
It is important to consider that parents in Gaza are often overburdened with attempting to provide basic needs (including safety and security) for children and other family members and may be unable or unwilling to participate in the homework activities assigned to children through their CBT intervention. It may be difficult for parents to understand or accept that children are participating in such an intervention when the atmosphere of family tension or trauma exists.
Fifth, the duration of the intervention and number of sessions are not enough to enhance a child’s skills to reconstruct resilience in their everyday practices. Further, the study has not explicitly used resilience as an outcome criterion, as the primary focus is on symptom reduction as an effectiveness criterion. Therefore, there is a concern that the individual-focused CBT approach is not necessarily appropriate to diverse cultural and social backgrounds that value spiritual and collective grief and curative rituals (Hays &
Iwamasa, 2006).
Sixth, the conceptualization of resilience was largely through child- and family-related factors, ignoring wider political, cultural, and societal resources (Ungar, 2012, 2013). Such resources could be civil society organizations, youth clubs, religious places (mosques), summer camps at local NGOs, children’s cultural and educational centres. In the Palestinian context, utilizing existing community resources and strengthening collective coping capacities is respectful of a culture based on community and family groups.
Seventh, the study also includes single-source and subjective reporting of peer and sibling relations. Also, children reported mental health indicators instead of more valid clinical interviews. Multiple reporting, represented by (parents, teachers and peers) as sources of information would have given a more dynamic and comprehensive look and strengthened the setting.
Eighth, the generalization of the results should be limited to the aftermath of major wars and military conflict such as the Syrian war, where children are exposed to major traumas, family separations, and displacement. Improving children’s social relations, building their resilience, and enhancing their skills in regulating their emotions should be the target of the psychosocial interventions.
Lastly, the study deserves criticism for the conceptualization and measurement of ER, the self-reported nature of the independent and dependent variables, cross-sectional study setting and low reliability of one scale (distracting ER). Also, the reliabilities and validity
of ERQ content dimensions need further testing in different trauma and cultural contexts.
Additionally, a longitudinal study would provide information on the role of ER in mental health changes when war fears diminish.