Effects of Political Violence on Children: A Social Ecological Perspective, Ejercicios de Biología

¡Descarga Effects of Political Violence on Children: A Social Ecological Perspective y más Ejercicios en PDF de Biología solo en Docsity! The Israeli–Palestinian conflict: Effects on youth ture Contents lists available at ScienceDirect Developmental Review journal homepage: www.elsevier.com/ locate /dr Developmental Review 43 (2017) 1–47adjustment, available interventions, and fu research directions Laura E. Miller-Graff *, E. Mark Cummings University of Notre Dame, Notre Dame, IN 46545, USA A R T I C L E I N F O A B S T R A C T litical vio- one of the ted nega- f children cript is to th in Israel h. Results sed to po- ng on the lestinian– indicating g., stigma, ptualizing include a inal work modera- nt studies. s that in- retically- rstanding e and the including reserved.Article history: Received 20 November 2014 Revised 16 September 2016 Keywords: Israel Palestine Political violence Risk and protective factors Children Youth Adolescents A large number of children are exposed to on-going po lence around the world. The Israeli–Palestinian conflict is longest on-going conflicts in the world and its documen tive effects on the health, development, and well-being o and youth are profound. The aim of the present manus provide an updated review of research on children and you and Palestine including both basic and treatment researc indicated that rates of psychopathology in children expo litical violence are high, but fluctuate greatly dependi sample and timing of data collection. Palestinians and Pa Israelis evidence higher rates of exposure and distress, that considerations of elements of the social context (e. access to resources) are important to evaluate in conce children’s reactions to political violence. Identified gaps lack of focus on resilient outcomes, a dearth of longitud resulting in an incomplete assessment of mediators and tors of change, and a relatively small number of treatme Suggested future directions include longitudinal studie corporate contextual (e.g., social ecological) and theo based (e.g., emotional security theory) directions for unde children’s functioning after exposure to political violenc development of translational treatment paradigms also these elements. © 2016 Elsevier Inc. All rights Available online 1 November 2016 * Corresponding author. University of Notre Dame, Notre Dame, IN 46556, USA. Fax: (574) 631-8883. E-mail address: lmiller8@nd.edu (L.E. Miller-Graff). http://dx.doi.org/10.1016/j.dr.2016.10.001 0273-2297/© 2016 Elsevier Inc. All rights reserved. A large number of children are exposed to on-going political violence around the world. Cur- rently, the number of refugees worldwide is approximately 43million, 41% of whom are children (United t one of violence eated in that has war and ing refu- ent, and n, 2012; nce have und the 2 L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47Nations, http://www.un.org/en/globalissues/briefingpapers/refugees/). Palestinians represen the largest refugee populations in the world, and for those still living in Israel and Palestine, is chronic. The Israeli–Palestinian conflict has been on-going since the state of Israel was cr 1948, representing one of the longest intractable conflicts and the only nation in the world never had a “conflict free” year (Human Security Report, 2009/2010). Chronic exposure to mass trauma place children at extremely high risk for a host of negative consequences includ geeism, lack of access to basic needs, physical health problems, developmental maladjustm long-termmental health problems (Cliff & Noormahomed, 1993; Hick, 2001; Masten & Naraya Wachs & Rahman, 2013). Several theoretical papers and literature reviews on the topic of children and political viole been written to help summarize and synthesize the diverse scope of on-going research arolitical vi- political cts mul- tancourt s, 2013). and pro- 012; Tol ilar con- tegration ugeeism, esmann h priori- urposes.world. There are several points upon which reviews and theory papers on the effects of po olence on children (globally) converge. First, there is general agreement that the effects of violence on children are necessarily understood multisystemically, as political violence affe tiple facets of children’s familial, neighborhood, and community contexts (Betancourt, 2012; Be & Khan, 2008; Dubow, Huesmann, & Boxer, 2009; Masten & Narayan, 2012; Tol, Song, & Jordan There is also a growing insistence on understanding both psychopathology and protective motive factors that are pertinent to resilience (e.g., Barber, 2009, 2014; Masten & Narayan, 2 et al., 2013). Unlike research on other types of childhood trauma, which underscores sim cepts, summative work on political violence and children calls for the consideration and in of unique and context-specific domains, including political ideology, hatred, displacement/ref and child combatant history (e.g., Barenbaum, Ruchkin, & Schwab-Stone, 2004; Dubow, Hu et al., 2009). While broad reviews are critically important to forming field-wide advances in researc ties, design, and methods, more focused reviews are able to serve a number of important p Reviews focusing on a specific construct (e.g., resilience; Barber, 2013; Tol et al., 2013) or on a par- re depth ore spe- e social- ities that , context n assess- er, 2014; ocumen- priorities provide on chil- c review onstrate amäki, & n adjust- he social eview of ich exist- amming. rch (e.g., as com- nt of the nd youth rotectiveticular region (Israel–Palestine; Dimitry, 2012) are advantaged in that they can provide mo and documentation of contemporary work in a particular topical domain or region. These m cific regional reviews often reflect the core structure of reviews in the field at large (e.g., th ecological model; Betancourt, 2012), but are able to address the deeper contextual particular can inform translational research and intervention in specific geographical regions. Further specific reviews allow for a more nuanced evaluation of context-specific considerations i ment and treatment; a priority that has been underscored by many researchers (Barb Barenbaum, Ruchkin & Schwab-Stone, 2004). Region-specific reviews also provide critical d tation of the extent to which research in a specific context or topical area reflects contemporary articulated in theoretical and global review work. One goal of the current review, then, is to region-specific depth and analysis within a common contemporary framework for research dren and political violence – the social ecological model. The current review must also be situated within the context of previous region-specifi work. Previous reviews of the effects of the Israeli–Palestinian conflict on children also dem clear negative effects on child adjustment (Dimitry, 2012; Sagi-Schwartz, 2008; Qouta, Pun El Sarraj, 2008), but extant work focuses primarily on summarizing the effects of violence o ment and has engaged in more limited explorations of risk and protective factors across t ecology (with the exception of Qouta, Punamäki, Miller, & El-Sarraj, 2008). In addition, no r the psychological literature in Israel and Palestine has clearly articulated the extent to wh ing basic research is capable of and used to inform the development of intervention progr This is, perhaps, because extant reviews have only considered a portion of available resea Qouta et al., 2008 review only their own work; 50–71 studies are included in other reviews pared to 114 in the current review; see Fig. 2). Tables 1–4 thus provide an extensive treatme extant literature, the most comprehensive to this point, on the Israeli–Palestinian conflict a adjustment Throughout this review, also reflected in Tables 1–4, context-specific risk and p factors are addressed. Results After published articles were collected and screened, the authors read and reviewed the content of each in light of the established study objectives (see Fig. 1). In this section, we assess questions 1–4, which evaluate the state of current basic and treatment research in the region. The results for each objective are presented sequentially, here. Following the evaluation of objectives 1–4, we syn- thesize and critically review these findings in the discussion section in order to address the fifth and final objective (see Fig. 1). In this way, we hope to establish a clear framework for understanding in- dividual effects and processes (exposure to violence objective 1; individual levels mediators and moderators, objective 2) within the relevant social ecological context (objective 3) and review the extent to which the current treatment literature has reflected the particular needs and priorities identified in basic research (treatment research, objective 4). All of the studies reviewed are included in Tables 1–4, which are organized based on the type of study (basic or treatment research) and age group exam- ined (children, adolescents, mixed; see Fig. 2). The tables include information about the sample (participants, region), when data were collected (if reported), the assessments used, and a summary of primary findings. Original Search 186 unique articles returned Examination of Abstracts for Relevance to Review Topic 52 not relevant 4 studies of violence exposure/aggression in other domains w/no reference to IP conflict 9 commentary/review/theoretical 3 case studies 1 not in English 1 with an international sample and no analyses specific to Israel/Palestine 1 with very little sample data 1 with very little empirical intervention data 114 articles Basic research vs. Treatment Research Basic Research (Tables 1-3) Children (0-13 years): 31 articles Adolescents (13+ years): 42 articles Mixed age: 25 articles Treatment (Table 4) Children (0-13 years): 6 articles Adolescents (13+ years): 5 articles Mixed age: 5 articles Sample Israeli: 19 articles Palestinian-Israeli: 2 articles Palestinian: 51 articles Multi-sample studies: 26 articles* *Most, but not all multi-sample studies, evaluated Jewish-Israeli and Palestinian-Israeli samples Sample Israeli: 6 articles Palestinian-Israeli: 1 article Palestinian: 8 articles Multi-sample studies: 1 article* *Most, but not all multi-sample studies, evaluated Jewish-Israeli and Palestinian-Israeli samples Fig. 2. Search and inclusion criteria flow chart. 5L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 Exposure to violence (objective 1) Before examining the effects of exposure to violence, it is essential to understand how exposure to political violence has been evaluated in Israel and Palestine, and the implications of measurement for interpreting relationships between constructs (i.e., political violence and adjustment). The most notable challenges to interpreting and integrating data on exposure to political violence in Israel and Palestine and understanding its relationship to children’s psychological functioning are (1) the great diversity of assessments used and (2) the timing at which such assessments were administered. In studies conducted in Israel, one of themost commonly used assessments is the Political Life Events (PLE) Scale (Slone & Hallis, 1999). Events in this checklist describe a range of exposure from “mild” (e.g., security drill at school) to “severe” (e.g., injury of friend or acquaintance), and include direct, indirect, and “known” forms of exposure (e.g., knowing someone who has witnessed political vio- lence). One of the most commonly used trauma checklists used in studies conducted in Palestine is the Gaza Traumatic Event Checklist (Abu Hein, Qouta, Thabet, & el Sarraj, 1993). Unlike the PLE, this checklist, as it is typically used, includes only direct exposure and severe indirect exposures (e.g., wit- nessing shooting of a close relative). In the scoring for each, most studies conducted in Palestine create a sum score of traumatic events without scaling for severity of event. In contrast, the PLE “down- scores” for mild events (value of 0.5) and “up-scores” for severe events (value of 1.5). When examining rates of violence exposure across studies, then, the mean value of exposure to violence is quite mis- leading as an Israeli child who has been exposed to security drills at school and a security check in a public space (both valued at 0.5) would have the same exposure score (1) as a Palestinian child who reported tear gas inhalation (who would receive a tally score of “1” on the Gaza Traumatic Event Check- list). Problematically, the presence of different scoring systems and the failure to assess “exposure events” in the same way across groups has led to a false sense of equivalency in the literature regarding the extent and severity of traumatic exposures across groups. Based on a more in-depth examination of the qualitative meaning of endorsed responses across studies, and the few studies conducted using the PLE across samples, it is evident that Palestinian (and Palestinian–Israeli) children are more frequently and severely exposed to political violence, although the link between political violence exposure and maladjustment holds for all groups (see Tables 1–3). For example, a longitudinal study of Palestinian children in Gaza (randomly selected fromwithin upper and lower quartiles of traumatic exposure from a previous poll; collected in 1993) reported that 82% of children were exposed to tear gas attacks, 74% were exposed to night raids, and 53% had a family member imprisoned (Qouta, El-Sarraj, & Punamäki, 2001; see Table 1). A study of Palestinian adoles- cents from the West Bank and East Jerusalem (n = 1185, convenience sample 13 schools with children randomly selected from within each grade) found that 79.8% of adolescents reported the experience of prolonged curfews, 50.8% reported attacks and 30.6% reported the injury of a family member by settlers or soldiers (Haj-Yahia, 2008; Table 2). Palestinians, generally speaking, are more likely to ex- perience direct victimization than are Israeli youth (Klodnick, Guterman, Haj-Yahia, & Leshem, 2014; sampled from diverse locations not considered to be “confrontation line” communities) and in re- cently collected samples, as many as 20% of youth report being injured and 20% report having been shot at (Thabet, El-Buhaisi, & Vostanis, 2014; randomly selected from schools in the Gaza Strip). As- sessments of political violence exposure in Palestine also frequently include items related to humiliation by the military – an aspect of violence exposure that has been linked to increased health complaints in adolescents (Giacaman, Abu-Rmeileh, Husseini, Saab, & Boyce, 2007). Importantly, both direct vic- timization and collective victimizations have been shown to have independent and negative effects on adolescent mental health (Giacaman, Shannon, Saab, Arya, & Boyce, 2007). Collective victimiza- tions most often refer to traumatic events experienced by a large number of individuals simultaneously (e.g., tear gas attack, terrorist attack) while individual victimizations refer to those traumatic events occurring directly to the individual (e.g., beatings, torture). In the context of Israel and Palestine, many of the structural and overt forms of violence are collective in nature, and may be more frequently re- ported (e.g., Giacaman, Shannon, et al., 2007), but individual experiences of violence – even those with sociopolitical implications – are present and place individuals at risk as well. There is also evidence of gender differences in exposure to violence. For example, several studies conducted at different points in time show that Palestinian males are more highly exposed than Palestinian females (Giacaman, 6 L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 Table 1 Basic research, children (0–13). Study (authors, year of publication) Participants (age, national background) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Summary of main findings Boxer et al., 2013 Palestinian, Israeli-Jews, Israeli-Arab (8, 11 and 14 years, n = 1501 at baseline) Palestine (2007– 2009) Israel (2007–2010) (L); Demographics questionnaire, Exposure to Conflict and Violence scale, Exposure to Intraethnic Community Violence scale, Exposure to School Conflict and Violence scale, Exposure to Family Conflict and Violence scale, Severe Physical Aggression scale Ethnopolitical violence increases community, family, and school violence and children’s aggression. Palestinian children are at greatest risk of exposure to various forms of violence and for exhibiting various forms of aggressive behavior. Brenick et al., 2010 Israeli-Jewish, Palestinian-Israeli, Palestinian, Jordanian (preschool and kindergarteners n = 433) Israel and West Bank (not reported) (C); Knowledge About the Outgroup, Evaluations of Exclusion Israeli-Jewish children were more likely to provide a neutral attribute to a member of the outgroup, rather than a positive or negative one. Israeli-Palestinian children were more likely to provide a positive attribute to a member of the outgroup, rather than a neutral or negative one. Both Jordanian and Palestinian children were more likely to provide negative attributes to a member of the outgroup, rather than a neutral or positive one. Deeb et al., 2011 Phase 1: Secular Jews, and Arabs (2nd and 6th graders, n = 104) Phase 2: Secular Jews, Muslim Arabs and Arabs (kindergarteners, 2nd and 6th graders, n = 192) Phase 3: Secular Jews, Muslim Arabs and Arabs (kindergarteners, 2nd and 6th graders, n = 375) Israel (not reported) (C); Phase 1: “Guess Who?” game (C); Phase 2: story (L); Phase 3: Essentialism Components Questionnaire (ECQ) Exposure to ethnic diversity increased the salience of ethnicity, especially for Jewish children. All kindergarteners started off at a similar level of essentialism toward ethnicity exposure affected Arab, but especially Jewish, children’s essentialist beliefs. Dubow, Boxer et al., 2012 Palestinian, Israeli-Jews, Israeli-Arabs (8, 11 and 14 years, n = 1501 at baseline) West Bank, Gaza Strip and Israel (not reported) (L); Demographics questionnaire, Exposure to Ethnic-Political Conflict and Violence scale, Exposure to Intraethnic Community Violence scale, Exposure to School Violence scale, Exposure to Family Violence scale, Child Post Traumatic Stress Symptoms Index Effects of exposure across all four contexts (ethnic- political, community, family, school) on posttraumatic stress (PTS) varied between the samples. Unique effects were observed on subsequent PTS symptoms of exposure to ethnic-political conflict violence in one sample (Palestinians), school conflict violence in two samples (Palestinians and Israeli Jews), and family violence in one sample (Israeli Arabs), even after controlling for youth’s initial PTS levels. (continued on next page) 7 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 1 (continued) Study (authors, year of publication) Participants (age, national background) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Summary of main findings Punamäki, 1996 Jewish Israeli (10–13 years, n = 385) Lebanon border towns, West Bank settlement, “low tension” villages (not reported) (C); Psychosocial problems scale (study developed), Attitudes Toward War and Peace Questionnaire, Political and Everyday hardships (study developed) Boys reported higher levels of injury and loss than did girls. Violence exposure varied significantly across geographic areas. Boys and those from “high tension” areas reported higher levels of glorification of war and more pessimistic attitudes toward peace. Ideological commitment was a protective factor in the relationship between exposure to violence and internalizing symptoms. Punamäki and Puhakka, 1997 Palestinian (10–13 years, n = 185) West Bank (n = 89 collected in 1985; n = 96 collected in 1991) (C); Six Unfinished Sentences, Psychosocial Problems Scale, Stressful Events Checklist Children in the Intifada (1991) sample were more likely to use social affiliation as a coping strategy. Children in the pre-Intifada (1985) were more likely to use active fighting as a coping strategy. Exposure to violence predicted the use of all coping skills except avoidant distraction. Punamäki, Qouta, and El Sarraj, 1997a Palestinian (11–12 years, n = 108) Gaza (1993) (C); The Traumatic Events Checklist, Schaefer’s Parental Inventory Scale, Political Activity assessment (study developed) Higher level of exposure to violence was related to higher levels of political activity; boys reported higher levels of political activity than did girls. Higher child exposure to trauma was related to more restrictive and negative parenting practices. In highly exposed families, fathers were supportive of boys’ political activity. Punamäki, Qouta, and El Sarraj, 1997b Palestinian (11–12 years, n = 108) Gaza (1993) (C); The Traumatic Events Checklist, Schaefer’s Parental Inventory Scale, Eysenck Neuroticism Scale, Rosenberg Self-Esteem Inventory, Saleh Picture IQ test, Abraham Creativity Test, WISC coding & digit span, Political Activity assessment (study developed) Mediation analysis of cross-sectional data found that parenting style and political activity mediated the relationship between exposure to trauma and psychosocial adjustment, with high exposure to trauma being associated with more negatively perceived parenting styles and greater political activity, in turn predicting poorer adjustment. Punamäki and Joustie, 1998 Palestinian (7–12 years, n = 80) Palestinian-Israeli (7–12 years, n = 45) Finnish (7–12 years, n = 80) Galilee, Israel (n = 45) Gaza (n = 80) Finland (n = 80) (1993) (C); Semi-structured dream and sleep inventory Living in violent environments was associated with higher reports of dreams with aggressive or persecution themes. (continued on next page) 10 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 1 (continued) Study (authors, year of publication) Participants (age, national background) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Summary of main findings Qouta et al., 2001 Palestinian (Phase 1: 10– 12 years, n = 108; Phase 2: 13–15 years, n = 86) Gaza (1993 and 1996) (L); Phase 1: Traumatic Events Checklist, two mental flexibility tasks, Eysenck Neuroticism Scale (SENQ), Rosenberg’s Self-Esteem Scale, Saleh Picture IQ Test Phase 2: Ontario Child Health Scale (OCHS), Frederick, Pynoos and Nader (1992) PTSD scale Boys experienced more traumatic events and psychological adjustment problems than girls. No gender differences were found in PTSD or self-reported emotional disorders at follow-up. At follow up, mental flexibility appeared to attenuate the impact of trauma on emotional disorder development, but did not moderate the negative effects of traumatic events on PTSD at the follow-up. Qouta, Punamäki, and El Sarraj, 1995a Palestinian (11–12 years, n = 64) Gaza (1992, 1994) (L); The Traumatic Events Checklist, Participation in flag raising (item), Saleh Picture IQ test, Eysenck Neuroticism Scale, Abraham Creativity Test, Political Activity assessment (study developed) Past exposure to trauma was related to higher neuroticism and lower self-esteem after the peace treaty (1994), but participating in post-treaty festivities was protective. Children’s creativity predicted to change in neuroticism from T1 to T2. Qouta, Punamäki and El Sarraj, 1995b Palestinian (11–12 years, n = 108) Gaza (1993) (C); Political Activity assessment (study developed), Saleh Picture IQ test, WISC coding & digit span, Eysenck Neuroticism Scale, Abraham Creativity Test, Risk Taking Tendency (study developed), Rosenberg Self-Esteem Inventory Those with a higher level of traumatic exposure were more likely to report activity in the Intifada. Among those with a lower level of exposure, boys were more likely to participate in the Intifada than girls. Trauma exposure was related to high neuroticism and risk taking; Intifada involvement was related to low self-esteem Shechtman and Basheer, 2005 Palestinian (11–12 years, n = 186) Israel (2003) (C); Revised Normative Beliefs Measure, The Index of Empathy for Children and Adolescents, Intergroup Anxiety Scale On average, participants supported an aggressive reaction to a child of an out-group (Jewish) more than to a child of their own group and exhibited a greater degree of empathy toward a child of their own group. Girls showed a lower level of general normative beliefs supporting aggression, higher level of general empathy, and higher level of intergroup anxiety than boys. Slone and Hallis, 1999 Israeli (12–13 years, n = 397) Central Tel Aviv area, Golan Heights and West Bank (not reported) (C); Political Life Events (PLE) scale, Brief Symptom Inventory (BSI), General Severity Index (GSI) There was a positive linear relationship between the severity of exposure to PLE and level of psychological distress, with girls showing higher levels of psychological distress than boys. (continued on next page) 11 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 1 (continued) Study (authors, year of publication) Participants (age, national background) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Summary of main findings Slone et al., 1999 Israeli (12–13 years, n-397( Central Tel Aviv area, Golan Heights and West Bank (not reported) (C); Political Life Events (PLE) scale, perception threat factors, ideology factor, Brief Symptom Inventory (BSI), Ideology did not mediate the relationship between political evident and distress. Slone et al., 2011 Jewish (10–11 years, n = 52) Arab-Israeli (10–11 years, n = 42) Haifa, Israel (not reported) (C); Parenting Styles and Dimensions Questionnaire, demographic questionnaire, Brief Symptom Inventory (BSI), Political Life Events (PLE) Scale, Negative Life Events Scale, General Severity Index (GSI) Children exposed to high levels of political life events (PLE) reported higher levels of general psychological distress than children who were exposed to low levels of PLE. Children of authoritarian mothers reported higher levels of general psychological distress on the GSI than both children of authoritative and children of permissive mothers. Thabet and Vostanis, 1999 Palestinian (6–11 years, n = 239) Gaza (1998) (C); Rutter A2 (Parent) Scale, Rutter B2 (Teacher) Scale, Gaza Traumatic Event Checklist, Child Posttraumatic Stress Reaction Index Most commonly reported type of political violence exposure was tear gas inhalation (56.1%); 72.8% of the sample had at least mild levels of PTSD symptoms and 41% reported moderate to severe symptoms Thabet and Vostanis, 2000 Palestinian (7–12, n = 234) Gaza (1998 (baseline); follow- up 18 months later) (L); Rutter A2 (Parent) Scale, Rutter B2 (Teacher) Scale, Gaza Traumatic Event Checklist, Child Posttraumatic Stress Reaction Index Only 10% of children reported moderate to severe symptoms of PTSD at follow-up (down from 41%); past exposure to violence was the strongest predictor of PTSD symptoms at follow-up. Thabet et al., 2006 Palestinian (3–6 years, n = 309) Gaza (2002–2003) (C); Gaza Traumatic Checklist-Parent Form, Behavior Checklist, Strengths and Difficulties Questionnaire Exposure to violence was higher; exposure to day raids and shelling of children’s houses was significantly related to emotional and behavioral problems. Zakrison et al., 2004 Palestinian (6–13 years, n = 206) West Bank (2002) (C); Rutter A2 (Parent) Scale, Socioeconomic Adversities Questionnaire 42.3% of children in the West Bank showed psychological morbidity. 12 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 2 (continued) Study Participants (age range) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Primary finding(s) Elbedour, 1998 Phase 1: Bedouin/West Bank Palestinian/Gazan (13–19 years n = 356) Phase 2: Gaza/Israeli Bedouin/Jewish from Negev region (14–19 years n = 331) Phase 1: Negev region, West Bank, Gaza (1992) Phase 2: Negev region, Gaza (1994) (C/L); The Derogatis Symptom Checklist-Revised, The Coopersmith Self-Esteem Inventory (Adolescent version) Psychopathology was significantly higher among Gazan youth than Israeli Jewish or Bedouin youth. Gazan youth had the lowest levels of self-esteem. Elbedour et al. 2007 Palestinian (14–19 years n = 229) Gaza (2002) (C); The post-traumatic stress disorder interview, The Beck Depression Inventory-II, The Beck Anxiety Inventory, The Coping Responses Inventory 68.9% of participants had PTSD, 40% reported moderate or severe levels of depression, 94.9% exhibited severe anxiety. Adolescents diagnosed with PTSD reported the highest levels of depression, anxiety, and positive reappraisal coping, and the lowest levels of seeking guidance and support coping. Elbedour et al.,1998 Bedouin/Palestinian (13–18 years n = 356) Negev region of Israel, Gaza, and the West Bank (not reported) (C); The Derogatis Symptom Checklist-Revised, PTSD Checklist, Rotter’s Internal/External Locus of Control, Drawing analysis Bedouin adolescents in Israel showed elevated rates of psychopathology, illustrating the possible effect of social upheaval in addition to exposure to violence in psychopathology. Even-Chen and Itzhaky, 2007 Jewish Israelis (13–17 years n = 254) Israel (not reported) (C); Exposure to domestic or community violence, Exposure to terrorism, Social and family support, Mastery, Beck Hopelessness Scale, Life satisfaction, Direct and Indirect Aggression Scale Exposure to terrorism contributes significantly to violent behavior. Exposure to domestic and community violence and mastery also contributed to explaining the variance in violent behavior. Giacaman, Abu-Rmeileh et al., 2007 Palestinians (15–18 years, n = 3415) West Bank (2003) (C); Derivation of the World Health Organization’s Health Behavior in School-aged Children (HBSC; psychosomatic complaints and emotional health), Gaza Traumatic Events Checklist Exposure to violence was high and males reported more exposure than females; both exposure to political violence and exposure to humiliation were linked to subjective health complaints Giacaman, Shannon et al., 2007 Palestinians (15–18 years, n = 3415, same as above sample) West Bank (2003) (C); Derivation of World Health Organization’s HBSC, Individual and Collective Exposure to Violence by Israeli soldiers/settlers, Gaza Traumatic Events Checklist, depressive-like state (study developed) Exposure to both collective and individual types of violence had independent and negative effects on adolescent mental health; girls and those living in refugee camps had the highest prevalence of depressive-like symptoms Guterman, Haj-Yahia et al., 2010 Arab/Jewish (junior and senior high school students n = 1835) Israel (not reported) (C); Exposure to Community Violence, Barriers to Help-Seeking in the Wake of Violence There is widespread exposure to community violence, especially for the Arab students. Adolescents sought help from a mental health professional. Haj-Yahia 2008 Palestinian (14–20 n = 1185) West Bank and East Jerusalem (2000) (C); Family Inventory of Political Stressors, Psychological Adjustment Scale, Youth Self Report Both internalizing and externalizing symptoms related to reports of exposure to political violence during the first Intifada. (continued on next page) 15 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 2 (continued) Study Participants (age range) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Primary finding(s) Haj-Yahia and Abdo-Kaloti 2003 Palestinian (14–20 years n = 1185 same sample as above) West Bank and East Jerusalem (2000) (C); Conflict Tactics Scales, Family Inventory of Political Stressors, Psychological Adjustment Scale There were high rates of witnessing and experiencing domestic violence, which were significantly related to several socio-demographic characteristics. Haj-Yahia and Abdo-Kaloti, 2008 Palestinian (14–20 years n = 1185) West Bank and East Jerusalem (2000) (C); Youth Self Report, Conflict Tactics Scales, Family Inventory of Political Stressors, Psychological Adjustment Scale Variance in participants’ withdrawal, somatization, anxiety and depression, social problems, thought problems, attention problems, delinquent behavior, and aggressive behavior were related to their exposure to abuse and violence exposure in childhood and adolescence. Khamis, 2005 Palestinian (12–16 years n = 1000) West Bank and East Jerusalem (1999) (C); Structured clinical interview for PTSD, Child Psychological Maltreatment Scale, Gender Inequities Scale, Family Ambiance Scale, Parental Support Scale, Harsh Discipline Scale, Economic Pressure, Fulfillment of Child’s Material needs Thirty-four percent of children met the criteria for PTSD; the presence of PTSD was associated with being male, a refugee, working and having high levels of anxiety in the family system. Khamis, 2008 Palestinian (12–18 years, n = 179, all boys with injuries from Al-Aqsa Intifada) West Bank and Gaza (not reported) (C); Structured clinical interview for PTSD, Revised Children’s Manifest Anxiety scale, Kidcope, Parental Support Scale, Fatalism scale (study constructed) Over three quarters of injured adolescents qualified for a PTSD diagnosis, almost one third of whom exhibited delayed onset. Parental support and coping were higher in those whose injuries were less recent. Fatalism and negative coping were most predictive of the presence of PTSD. Kimhi et al., 2010 Israeli (12–18 years n = 820) Kiryat Shemona, Northern Israel (2007) (C); Brief Symptom Inventory, Posttraumatic recovery, Solomon and Prager’s sense of safety scale, family cohesiveness, exposure to traumatic war events instrument A minority complained about high-level prolonged postwar symptoms. Another minority indicated posttraumatic recovery. The relationship between exposure to war distress and stress symptoms/ posttraumatic recovery was mediated by family support and subjective sense of danger. Kira et al., 2011 Palestinian (12–19 years n = 880) West Bank and Gaza (2005) (C); Identity Salience Scale, Cumulative Trauma Scale, Fear of Death and Dying measure, Annihilation Anxiety Measure, CAPS-2, CESD, DASS-Anxiety, Cumulative Trauma Disorders Measure Personal identity traumas were related to higher levels of mental health problems and fear of death; collective traumas were associated with higher levels of identity commitment and militancy Kira et al., 2014 Palestinian (n = 438) West Bank (2005) (C); Cumulative Trauma Scale, Identity Salience Scale, Annihilation Anxiety Measure, CAPS-2, CESD, Cumulative Trauma Disorders Measure, Health Problems Measure, single item measures of coping and posttraumatic growth Collective trauma was the most commonly reported type of traumatic exposure and was highly associated with other types of traumatic exposures and negative appraisals of traumatic events; religious coping, political ideology, and social support emerged as protective factors for mental health (continued on next page) 16 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 2 (continued) Study Participants (age range) Region (year of data collection) Assessments, Research design (C = Cross-sectional, L = Longitudinal) Primary finding(s) Knafo et al., 2008 Jewish/Arab students (10th–12th grades n = 907) Israel (2005) (C); Portrait Values Questionnaire, Individual-level self-reported violent behavior, school level violence Power values were positively related, and universalism and conformity were negatively related to self-reported violent behavior. Kolltveit et al., 2012 Palestinian (12–17 years n = 139) Gaza (2010) (C); Gaza Traumatic Event Checklist, Revised Child Impact of Event Scale, Revised Children’s Manifest Anxiety Scale, Depression Self-Rating Scale for Children Adolescents reported elevated levels of intrusion, avoidance, and depression. Significant risk factors for PTSD were exposure, female gender, older age, and an unemployed father. Risk factors for anxiety were exposure, female gender, and older age. Laufer et al., 2009 Jewish-Israeli (16 years, n = 1482) Israel (2005) (C); Exposure to Terror Attacks Questionnaire, Life Events Questionnaire, Forgiveness Scale, Child Posttraumatic Stress Reaction Index, Posttraumatic Growth Inventory, Higher levels of subjective (but not objective) exposure to violence were associated with higher levels of posttraumatic growth for secular, traditional, and religious youth. Religious and traditional youth reported higher levels of posttraumatic growth than did secular youth. Laufer and Solomon, 2006 Israeli (13016 years, n = 2999) Judea, Samaria, Gaza, and other areas (not reported) (C); Child Post-Traumatic Stress Reaction Index; Posttraumatic Growth Inventory Exposure to violence was related to higher levels of reported posttraumatic growth. Religious adolescents reported higher levels of posttraumatic growth. Laufer and Solomon, 2009 Israeli (13–16 years n = 2999) Judea, Samaria, Gaza, and other areas (not reported) (C); Lavi’s exposure-to-war and terror questionnaire, Subjective Exposure (Fear), Ideological Commitment, The revised Religious Orientation Scale, Support Persons Scale, Girls reported more posttraumatic symptoms than boys, although boys reported twice the rate of very severe symptoms. Al-Krenawi, Lev-Wisel and Sehwail, 2007 Palestinian (12–18 years n = 1776) West Bank (not reported) (C); Domestic Violence (study developed), Political Violence Events (study developed), Family Assessment Device, Brief Symptom Inventory Socioeconomic status, family violence, exposure to political violence and family functioning were significant and independent predictors of psychological symptoms. Pat-Horenczyk et al., 2009 Palestinian (14–17 years n = 1235) Israeli (12–18 years n = 1016) West Bank cities Jerusalem, Israel (2004) (C); Objective exposure, subjective exposure, UCLA PTSD Reaction Index: Adolescent Version, Functional Impairment Questionnaire, Somatic Complaints Checklist, Brief COPE Direct and more intense exposure was associated with more posttraumatic symptoms across groups. Palestinians (who generally had more exposure than Israelis) reported greater posttraumatic distress. Functional impairment and somatic complaints were also higher in Palestinians than Israelis. Punamäki, Qouta, and El-Sarraj 2001 Palestinian (~11 years at T1 ~14 years at T2 n = 86) Gaza (T1: 1993, T2: 1996) (L); IQ, Abraham Creativity Test, Activity scale (attitude and behavior preferences concerning the Intifada), Schaefer’s Parental Behaviour Inventory Scale, The life- event scale, Ontario Child-Health Scale, PTSD (Frederic, Pynoos, and Nader), school performance, Eysenck’s neuroticism scale PTSD was high among the children who had been exposed to a high level of traumatic events and who had responded passively to Intifada violence. Cognitive capacity and activity contributed to resilience if children reported feeling loved and not rejected at home. (continued on next page) 17 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 3 Basic research, mixed age. Study Participants (Age, national Background) Region and year of data collection Assessments, Research Design (C = Cross-sectional, L = Longitudinal) Summary of findings Al-Krenawi, Slonim-Nevo, Maymon, and Al-Krenawi, 2001 Arab-Israeli (6th–8th grades, n = 100) Ju’arish, Israel (not reported) (C); Brief Symptom Inventory, Rosenberg Self-Esteem Inventory, McMaster Family Assessment Device Rates of reported symptoms were higher for children in this sample (living in a highly affected area) as compared to Israeli BSI norms; family functioning was a significantly associated with mental health. Espié et al., 2009 Palestinian (older than 1 year, n = 1369) Gaza Strip and Nablus area, West Bank (2005–2008) (C); Semi-structured interview, Questionnaires Depression was more common in adults than children; children and adolescents were at higher risk for PTSD. Following psychotherapy, a majority (79.0%) had improved symptoms. Garbarino and Kostelny, 1996 Palestinian (6–9 and 12–15 years, n = 150) West Bank (1990) (C); Demographic and Life History Information, Achenbach Child Behavior Checklist, Violence Questionnaire, The Conflict Tactics Scale (CTS) Form N, The Parenting Stress Index (PSI) Palestinian children displayed more behavioral problems overall on the Child Behavior Checklist than did children in the United States. “High risk” conditions resulted in gender and age differences in adjustment problems, with young children and boys being at highest risk. Helminen and Punamäki, 2008 Palestinian and Palestinian–Israeli (5– 16 years, n = 345) Gaza and Galilee, Israel (1993) (C); Semi-structured dream and sleep diary, Traumatic Events Checklist, Psychological Symptoms Scale Those with higher levels of trauma exposure reported more negative valence and emotionality in dream content than those with lower exposure. Adolescents and boys reported more intense emotionality in dream content than did younger children or girls. Khamis, 2012 Palestinian (6–16 years, n = 1267) West Band & Gaza (2006) (C); Strengths and Difficulties Questionnaire, Impact of Event Scale, Penn State Worry Questionnaires for Children In a cross-sectional evaluation, worry and posttraumatic stress mediated the relationship between political stressors and emotional and behavioral problems. Khamis, 2015 Palestinian (9–16 years, n = 205) Gaza (not reported; after 2013) (C); Trauma exposure scale (study developed), Strengths and Difficulties Questionnaire, Structured Clinical interview for PTSD, Eysenck Personality Questionnaire, Ways of Coping Questionnaire Children exposed to high levels of trauma were more likely to report emotional symptoms, neuroticism, and problem focused coping than children exposed to lower levels of trauma. Family income and emotion-focused coping were significantly related to emotional and behavioral problems. Peltonen, Qouta, El Sarraj, and Punamäki, 2010 Palestinian (10–14 years, n = 227) Gaza (2006) (C); Military trauma, Children’s Loneliness and Friendship Qualities questionnaires, Dunn Sibling Relation Scale, Child Depression Inventory, Strengths and Difficulties Questionnaire Boys reported higher exposure to military trauma, more depressive symptoms, and less sibling warmth than girls. Higher exposure to military violence was associated with poor friendship quality (especially for girls) and sibling rivalry. In a cross-sectional mediation model, peer and sibling relationship factors mediated the relationship between military trauma and mental health Punamäki, 1988 Israeli (10–13 years, n = 385) Near border with Lebanon, Jewish Settleman, Four “low tension” villages/towns (C); Psychosocial problems scale, ideological commitment, political and everyday hardships Exposure to political hardships was not associated with more psychosocial problems if children had high ideological commitment; political hardship was related to higher levels of ideological commitment. (continued on next page) 20 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 3 (continued) Study Participants (Age, national Background) Region and year of data collection Assessments, Research Design (C = Cross-sectional, L = Longitudinal) Summary of findings Punamäki, 1998 Palestinian (Trauma Group: 6–15 years, n = 268; Control Group: 6–15 years, n = 144) Gaza Strip (Trauma group) and Galilee, Israel (Control group) (1993) (C); Dream Diaries, The Traumatic Events Checklist Increased exposure to traumatic events was related to more psychological symptoms. Dreams of “mundane persecution” mediated the association between traumatic events and psychological well-being. Dysfunctional dreams and repetitive attack dreams were associated with poor psychological well-being. Punamäki, 1988 Palestinian & Palestinian refugees in Lebanon (8–14 years; n1 = 66, n2 = 42, n3 = 31) West Bank (Sample 1, 1982) West Bank (Sample 2, 1985) Beirut refugee camps (Sample 3, 1984) (C); Picture test for coping (study developed), study adapted version of the Fear Survey Schedule, Life Event Scale (study developed) Older children reported more active and purposeful coping tactics, boys more so than girls. Children exposed to higher levels of political violence reported more helpless coping tactics, as did children living in refugee camps. Punamäki, 1989 Palestinian & Palestinian Israeli West Bank, Gaza, Israel (1982) (C); Life event scale (study developed), psychological symptoms (adapted from Rutter screening tool), shortened version of Children’s Form of Manifest Anxiety Scale, items from the Fear Survey Schedule, mother report of family situation, Rotter locus of control (mother), Rotter Incomplete Sentence Blank, Multiple Affect Adjective Checking List Political hardship was significantly related to psychological symptoms. Girls reported higher levels of fear than boys. Family happiness and financial situation did not moderate the relationship between political hardship and psychological symptoms. High maternal locus of control and social-political activity was a protective factor for children. Child and maternal mental health symptoms were positively related. Punamäki et al., 2011 Palestinian (6–16 years, n = 640) Gaza (1996) (C); War Trauma Questionnaire, Ontario Child Health Scale, Resilience Classification (see description in the text), items assessing: parental mental health, parenting practices, school performance, ante- and peri-natal problems; medical health assessment Children in the “resilient” group had lower exposure to trauma than children in the “traumatized” group. Parents of children in the “resilient” group had fewer mental health difficulties than parents of children in the “traumatized” group. Resilience was associated with being male, having had fewer antenatal problems, and better current health and performance in school. Qouta and El Sarraj, 2004 Palestinian (10–19 years, n = 944) Gaza (not reported) (C); Trauma Questionnaire Scale, Posttraumatic Stress Disorder Scale, Open questions regarding problem solving Most prevalent types of violence exposure during Al-Aqsa Intifada were witness of funerals (94.6%) and shooting (83.2%) and seeing a friend or neighbor injured or killed (66.9%). 81.9% of children reported moderate or severe levels of PTSD symptoms. (continued on next page) 21 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 3 (continued) Study Participants (Age, national Background) Region and year of data collection Assessments, Research Design (C = Cross-sectional, L = Longitudinal) Summary of findings Qouta, Punamäki and El Sarraj, 2005 Palestinian (6–16 years, n = 121) Gaza (2002) (C); War Trauma Checklist, Eysenck Neuroticism Scale (EPQ), Allodi (1985) Scale, SCL-90-R Symptoms Checklist, Child Posttraumatic Stress Disorder Reaction Index (CPTS-RI), Rutter Parent Questionnaire Maternal mental health problems were predictive of child PTS, but good maternal mental health and low neuroticism could not protect children’s mental health from the negative effects of war trauma. Boys were at higher risk for PTS symptom development and had higher internalizing symptoms when both the mother and the boys themselves were exposed to high levels of war trauma. Girls were at higher risk for PTS symptom development and had higher internalizing symptoms when only the mother was exposed to high levels of war trauma. Qouta, Punamäki, Miller and El-Sarraj, 2008 Phase 1: Palestinian (6–16 years, n = 640) Phase 2: Palestinian (10–15 years, n = 224) Phase 1: Gaza (1997) Phase 2: Gaza (2005) (C); Phase 1: Military Violence Assessment, Ontario Child Health Scale, Barber [1999] Parenting Practices Assessment Scale Phase 2: Gaza Community Mental Health Programme Questionnaire, Multiple Aggression questionnaire Exposure to military violence was associated with higher levels of aggressive and antisocial behavior. Supportive and non-punitive parenting practices protected children from engaging in aggressive and antisocial behavior. Slone and Shoshani, 2014 Jewish-Israeli (12–17 years, n = 8727) Israel (1998–2011) (C); Personal Political Life Events (PLE) Exposure Scale, Brief Symptom Inventory (BSI) PLE exposure increased from the pre-Intifada to the Intifada peak, decreased during the Intifada recession, increased during the Lebanon war and peak missiles and showed a declining trend during the Gaza war and the global terrorism period. PLE exposure was positively correlated with psychiatric symptoms. Slone and Shechner, 2009 Jewish Israeli (10–18 years, n1 = 1653, n2 = 1043, n3 = 971) Israel Sample 1: 1998– 2000 Sample 2: 2001– 2002 Sample 3: 2003– 2004 (C); Political Life Events Scale, Life Events Scale, Brief Symptom Inventory Political life events were significantly related to total symptom severity. Psychological symptoms were highest during the Intifada peak (i.e., Sample 2). Slone and Shechner, 2011 Jewish and Palestinian Israeli (10–18 years, n1 = 1742, n2 = 1085, n3 = 973) Israel Sample 1: 1998– 2000 Sample 2: 2001– 2002 Sample 3: 2003– 2004 (C); Political Life Events Scale, Life Events Scale Rates of exposure were highest at the peak of the Intifada and Arab adolescents reported higher levels of exposure that Jewish adolescents in terms of both total events and severity of exposure (continued on next page) 22 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 hood and adolescence, although this only held for Jewish Israelis and Palestinians – not for Israeli Arabs. In this study Jewish-Israeli youth endorsed the highest level of negative stereotyping about the “other” (Niwa et al., 2014). Despite the negative effects of violence exposure on cognition, studies of cogni- tive effects also suggest that optimal conditions may facilitate positive, adaptive cognitions related to peace and intergroup relations. For example, one study that followed adolescents over time found that 3 months of relative “peace” in Israel in Palestine (following two suicide bombings) showed that ado- lescents’ negative attitudes may remit over time (Bar-Tal & Labin, 2001). Research on cognition has also considered social identity theory (Tajfel & Turner, 1979). Social iden- tity theory posits that the processes governing interpersonal situations differ from those governing group situations, which are influenced more highly by categorical assumptions. Generally speaking, members of a particular group (e.g., a national identity) are more likely to view members of their own group (i.e., “in-group”) as both more dimensional (i.e., there is significant variability in the charac- teristics of groupmembers) and better thanmembers of other groups (i.e., “out-groups”; Mullen, Brown, & Smith, 1992). Empirical research from segregated communities in Israel supports these theories, demonstrating the presence of higher empathy for members of the “in-group” and aggressive atti- tudes toward the “out-group” (Shechtman & Basheer, 2005; Teichman, Bar-Tal, & Abdolrazeq, 2007). Similarly, youth have been found to be more likely to view their “in-group” as more highly dimen- sional than the perceived “out-group” (Rouhana, 1999). Youth in more integrated contexts, however, may be less likely to make stereotyped attributions about ethnic identity (Deeb, Segall, Birnbaum, Ben-Eliyahu, & Diesendruck, 2011) and are likely to report more positive or neutral feelings toward the “out-group” (Brenick et al., 2010). Mediators and moderators of adjustment (objective 2) Despite the wealth of research on children and youth living in Israel and Palestine, very few studies have employed longitudinal designs, limiting the extent to which mediators and moderators of the relationship between exposure to violence and adjustment can be evaluated. In the studies reviewed here, only 16.3% were longitudinal (study designs are noted in Tables 1–3). For this reason, whether or not the reviewed mechanisms below act as mediators or moderators of mental health following exposure to violence is unclear, as cross-sectional mediational models may significantly overesti- mate the role of the proposed mediator (Maxwell, Cole, & Mitchell, 2011). The limited longitudinal research that does exist in addition to preliminary analyses conducted on cross-sectional investiga- tions gives us some insight, however, into relevant risk and protective factors. The examination of mediators and moderators of change is extremely important, especially if basic research is to suc- cessfully inform intervention work. In the translation of basic research, mediating variables may be potential mechanisms of treatment change; that is, these represent underlying processes that might be targeted to exert greater change on the desired target of change. Moderating variables, alterna- tively, give insight into protective factors, suggesting what resources might be bolstered to decouple violence and its negative effects. Self-esteem There is some evidence to suggest that exposure to political violence is related to lower self- esteem in children and youth (Dubow, Huesmann et al., 2012; Elbedour, 1998; Qouta, Punamäki, & El Sarraj, 1995a) and that self-esteem moderates the relationship between exposure to violence and development of posttraumatic stress symptoms over time. Unlike other types of mental health diffi- culties, which appear to fluctuate based on the level of political violence, it is unclear whether or not self-esteem improves following reductions in political violence (Elbedour, 1998), suggesting that it may be influenced by other societal level characteristics associated with but distinct from direct ex- posure. In particular, Elbedour (1998) suggests that the lack of improvement in youths’ self-esteem and psychological symptoms over time suggests the failure to address other key mediators/ moderators of change, including stereotyping and negative attitudes about the peace process. If self- esteem is, in fact, a moderating protective factor for children, the failure of self-esteem to improve after violence ceases may pose a significant and long-term risk for children living in conflict zones. 25L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 Religiosity and spirituality It is somewhat surprising that the potential mediating and moderating effects of religiosity and spirituality have been so rarely examined in this context, given the strong support for the protective role of spiritual practice in other contexts (Goeke-Morey et al., 2013; Howell & Miller-Graff, 2014; Paranjape & Kaslow, 2010). The few studies that have examined religiosity in the context of political violence in Israel and Palestine have found it to be associated with positive outcomes for both Israeli and Palestinian youth (Barber, 2001; Laufer, Raz-Hamama, Levine, & Solomon, 2009; Schiff, 2006). Studies of religiosity and well-being have confirmed the link between religiosity and well-being for Pales- tinian youth (Abdel-Khalek & Eid, 2011). In a cross-sectional evaluation of Palestinian youth, higher exposure to Intifada violence was related to higher religiosity, which was in turn associated with lower levels of antisocial behavior (Barber, 2001). This study also evaluated the moderating role of religi- osity and noted significant protective effects, which has been suggested by other work (Schiff, 2006). International samples have also suggested that religion is generally associated with the well-being of children and families, but the role of religion in the well-being associated with larger systems (e.g., neighborhood) is negligible (Bradshaw, Keung, Rees, & Goswami, 2011). In all, studies evaluating the potential mediating or moderating effects of religiosity in Israel and Palestine have been cross- sectional and therefore do not provide decisive conclusions regarding the role of religiosity over time. Emotional security In addition to feelings of self-worth, there is also some work suggesting that children’s emotional security, or their sense of safety and security in the environment, may play an important mediating role in child adjustment, especially in settings characterized by chronic conflict or mass trauma (Hobfoll et al., 2007). Emotional Security Theory (EST; Cummings & Davies, 2011) extends notions of emo- tional security to reflect a broader family and community perspective, postulating that children’s emotional security is an explanatory mechanism in relations between social ecological contexts of con- flict and violence (e.g., family, community) and children adjustment. Emotional security in the family and community has been found to play an important role in contexts where political violence is prev- alent (Cummings et al., 2009, 2010, 2012). Although studies in Israel and Palestine have not examined emotional security using standardized assessments, there are several studies that indicate its impor- tance. For example, in a sample of adolescents living on the Israel–Lebanon border (n = 820, 12–18 years), exposure to violence was related to a higher sense of danger, which in turn was related to stress symptoms (Kimhi, Eshel, Zysberg, Hantman, & Enosh, 2010). Similarly, community violence expo- sure, domestic violence exposure and a respondent’s sense of personal danger and changes in behavior following exposure to terrorism were all significantly associated (Even-Chen & Itzhaky, 2007). Further, Palestinian–Israeli adolescents report a lower sense of safety in the school environment as compared to their Jewish-Israeli counterparts (Yablon & Addington, 2010). Although feelings of safety for both groups was related to living in more difficult neighborhoods, the authors hypothesized the main effect associated with feelings of safety at school could have arisen from structural disparities in the char- acteristics of neighborhoods between Palestinian– and Jewish-Israelis. Power In a study that examined Jewish and Palestinian–Israelis together (n = 907), it was found that those holding “power” values (i.e., desire for social status gains through dominance) were more likely to report violent behaviors, and this relationship was strongest in schools where violence was more highly present (Knafo, Daniel, & Khoury-Kassabri, 2008), suggesting a possible moderating effect of school violence on the relationship between power values and violence perpetration. Such results suggest the importance of “social sanctions” against violence in the social microsystem. That is, beyond macro- level solutions to the cessation of violence, such as ceasefires, it may be equally as important for violence to be reduced in other environmental spheres (here, schools). Thus, at the level of the microsystem adults and educators should also be attentive to enhancing value systems that promote nonviolence. Political activity and ideological commitment Overall, the extent to which political activity and ideological commitment acts as a protective or a risk factor for children is unclear, and likely to be heavily linked to other context-specific 26 L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 characteristics that are not fully explored in current psychological empirical research (e.g., What is the outcome of political activity for the individual? Community building? Prison?). Generally speak- ing, political activity appears to bemore frequent in boys. In comparative study, motivation for nonviolent political participation has been shown to be higher in Arab–Israeli as compared to Jewish-Israeli ado- lescents (Slone, 2003). For those who are politically active, participating in political activities related to peace processes has been shown to be protective (Qouta et al., 1995a). Similarly, ideological com- mitment has been shown to be protective following exposure to political hardship (Punamäki, 1996). Ideological commitment has also been evaluated as a mediator of adjustment, but results in this domain have been more mixed (Slone, Lobel, & Gilat, 1999). Identity schemas The research on ideological commitment and political activity has recently been integrated into a theoretical framework for understanding the effects of political violence on children: the social- cognitive-ecological model (Dubow, Huesmann & Boxer, 2009). This model underscores emphasizing social processing and identity schemas as core mediating and moderating mechanisms of the rela- tionship between political violence and psychosocial adjustment. To form their theoretical model, Dubow, Huesmann and Boxer (2009) integrate data on political ideology and commitment con- ducted in Israel/Palestine with research on social information processing and normative beliefs about the acceptability of violence, conducted primarily in the United States or other conflict settings. There has been region-specific research on the contribution of political violence to the development of youths’ political ideologies (e.g., Gvirsman et al., 2016; Niwa et al., 2014). This research has demonstrated that ethno-political conflict in Israel Palestine is associated with negative stereotyping of the outgroup, with increases in negative stereotyping documented for Israeli Jews and Palestinians, but not Israeli Arabs (Niwa et al., 2014). This research, however, has been not yet been extended to examine the effect of these held negative ideologies on children’s psychosocial adjustment, as postulated by the social- cognitive ecological model (Dubow, Huesmann et al., 2009). As such, this area requires more research before clear intervention implications are evident. Influences from the broader social ecology (objective 3) Few studies regarding political violence exposure in Israel and Palestine have empirically as- sessed the characteristics of larger systems surrounding the child/youth, including the family, community and society. This is somewhat surprising given that political violence is understood as occurring at the community or societal levels (i.e., at the level of the exo-, macro-, or micro-systems, according to Bronfenbrenner’s social ecological model, 1977). It stands to reason, then, that multiple characteris- tics of the social ecologymay influence children’s consequent adjustment following exposure to political violence. Social-ecological theories also stipulate that characteristics of various systems dynamically interact to influence individual-level adjustment (e.g., children’s behavior problems may be recipro- cally related to parenting behavior). Because few studies conducted in Israel and Palestine take-up an explicitly multi-level, multi-system framework, drawing together data on social-ecological influ- ences from across studies is the only means currently to address the possible role of social- ecological influences. Ideally, however, future research will include more multi-level assessments to allow for the evaluation of context-specific patterns of interaction. Polyvictimization One of the first and most important considerations in understanding multi-systemic risk is iden- tifying how political violence exposure is related to violence exposure in other contexts. There is clear evidence of “trickle down” effects of political violence on violence in the social microsystem (Al-Krenawi, Graham, & Sehwail, 2007; Boxer et al., 2013; Cummings et al., 2012; Haj-Yahia & Abdo-Kaloti, 2003; Palosaari, Punamäki, Qouta, & Diab, 2013). That is, high levels of political violence exposure are linked to higher rates of family, school and interpersonal violence as well. Further, polyvictimization across the social ecology is related to higher risk for mental health problems over time, especially for Pal- estinians and Palestinian–Israelis (Al-Krenawi, Lev-Wiesel, & Sehwail, 2007; Dubow, Boxer et al., 2012; Haj-Yahia & Abdo-Kaloti, 2007). Together, these findings reflect the need for studies to consider 27L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 Table 4 Intervention studies. Study Participants (age range, n) Region (year of data collection) Assessments Intervention characteristics Summary of findings Barron et al., 2013 Palestinian (11–14 years, n = 90 intervention, n = 50 control) Nablus, West Bank CRIES-13, DSRS, TGIC, Impact on School Performance Scale, SDQ, traumatic event exposure Cognitive behavioral program, includes 5 sessions focused on normalizing trauma, responding to loss, and managing symptoms of PTSD Participation in the intervention was related to significant decreases in PTSD, depression, and grief. Berger et al., 2007 Israeli (2nd–6th grade, n = 70 intervention, n = 70 control) Hadera, Israel (2003) Exposure to terrorism, PTSD symptomology, Functional Impairment, Somatic Complaint, Separation Anxiety Classroom-based program with psychoeducation, meditative, bio- energy, art therapy and narrative components Participants in the intervention program had significantly lower levels of PTSD and other psychological symptoms at post- test than the control group. Gaboulaud et al., 2010 Palestinian (0–19 years, n = 399) West Bank & Gaza (2000–2006) Exposure to violence, DSM-IV- TR diagnosis Brief psychodynamic psychotherapy By the end of therapy (average of 6 sessions), approximately 80% of patients (including adults) had improved. Gilboa-Schechtman et al., 2010 Israeli (12–18 years, n = 14 PE, n = 14 TLDP-A) Israel (2005–2007) Schedule of Affective Disorders and Schizophrenia for School- Aged Children, Children’s Global Assessment Scale, CPSS, BDI, treatment expectancy and satisfaction, therapeutic alliance Prolonged Exposure: 12–15 weekly sessions (60–90 minutes) focused on exposure Time Limited Dynamic Therapy: 15–18 sessions (50 minutes) focused on “working through” the core issue by “sharing thoughts, daily difficulties, and free associations” Both programs were successful in reducing posttraumatic stress but the effects for PE were greater in magnitude. Loughry, Ager, Flour Khamis, Afana & Qouta, 2006 Palestinian (6–17 years, n = 300 intervention, n = 100 control) West Bank and Gaza (2003–2004) Child Behavior Checklist, Parental Support Scale, Hopefulness Scale: Youth Version Cultural and recreational activities, afterschool educational activities (both after school and week-long camps over school breaks) Children in the treatment group had fewer total adjustment problems at follow-up, but did not exhibit significant differences in hopefulness from the comparison group. Peltonen et al., 2012 Palestinian (10–14 years, n = 141 intervention, n = 84 control) Gaza (2005–2006) Military trauma exposure, Child Posttraumatic Stress Reaction Index, Child Depression Inventory, Strengths and Difficulties Questionnaire, items assessing friendship quality School Mediation Intervention Group based mediation program. Objectives: improve conflict resolution/dialogue, self-regulation, decrease aggressive behavior SMI was protective of further friendship deterioration, but had no effect on mental health symptoms, prosocial behavior, or improving friendships. (continued on next page) 30 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 4 (continued) Study Participants (age range, n) Region (year of data collection) Assessments Intervention characteristics Summary of findings Punamäki et al., 2014 Palestinian (10–13 years, n = 242 intervention, n = 240 control) Gaza (2009) Emotion Regulation Questionnaire for Children, War trauma (study developed), Children’s Impact Event Scale, Depression Self-rating Scale for Children, Strengths and Difficulties Questionnaire, Mental Health Continuum Short Form Teaching Recovery Techniques Group Based, CBT therapy aimed at developing coping and emotion regulation skills, providing psychoeducation and narrative/mind– body exercises The intervention was not effective in improving emotion regulation, although there were improvements for all children over time. Emotion regulation was association with better mental health. Qouta et al., 2012 Palestinian (10–13 years, n = 242 intervention, n = 240 control) Gaza (2009) Peritraumatic Dissociation Scale (adapted), Children’s Impact Event Scale, Depression Self-rating Scale for Children, Strengths and Difficulties Questionnaire Teaching Recovery Techniques Group Based, CBT therapy aimed at developing coping and emotion regulation skills, providing psychoeducation and narrative/mind– body exercises Boys in the intervention group had reductions from T1 to T2 in the percent above the clinical cutoff for PTSS, but not once baseline differences in symptoms were controlled. The intervention was effective in reducing PTSS only in girls with low levels of peritraumatic distress. Sadeh et al., 2008 Israeli (2–7 years, Study 1 n = 35, Study 2 n = 191 intervention, n = 101 control) Nitzanim camp, Israel (2006) War-related experiences scale, SCRL (PTSD measure created for study) Brief intervention focused on hugging and being hugged by a stuffed puppy. Study I examined individual intervention and Study II examined a group-based adaptation Huggy-Puppy was associated with reductions in distress for both individual and group administered conditions. Shechtman and Tanus, 2006 Arab/Palestinian– Israeli (12–17 years, n = 474) Israel (2003) Intergroup anxiety scale, Index of empathy for children and adolescents, Revised normative beliefs measure, Personality dimensions of differences scale, The program was designed to encourage “self-expression in regard to participants’ multiple identities and their feelings toward the Jews” and enhance “empathy toward the Jewish narrative” After the program, those participants who were Christian showed significantly increased empathy and decreased endorsement of aggression. Muslim participants showed reduced anxiety and religious identity. Israeli identity increased for Christian and Druze participants. Slone and Shoshani, 2008 Israeli (12–15 years, n = 96 primary intervention, n = 85 control intervention) Center and South of Israel (not reported) SDQ, Political Life Events, Life Events Scale, Purpose of Life Test, Social Support Matrix, Self-Efficacy Questionnaire, BSI Intervention limited to those with clinical range symptoms on the SDQ Primary intervention: experiential activities aimed at bolstering support, self-efficacy and problem solving Control intervention: program on general issues related to adolescence The primary intervention program was successful in reducing distress, but only for those exposed to low levels of political violence. (continued on next page) 31 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 Table 4 (continued) Study Participants (age range, n) Region (year of data collection) Assessments Intervention characteristics Summary of findings Slone et al., 2013 Israeli (16–17 years, n = 94 intervention, n = 85 control) Ashkelon, Israel (2008) BSI, SDQ, social support matrix, Self-Efficacy questionnaire for Children, Political Life Events scale, Experiential activities aimed at mobilizing support networks and fostering self-efficacy Intervention improved social support and self-efficacy and alleviated psychological distress. Thabet, Tawahina, El Sarraj, and Vostanis, 2008 Palestinian (6–16 years, n = 304) Gaza (2007–2008) Gaza Child Health Study Scales Student Mediation Program There was statistically significant improvement in children’s mental health symptoms from pre to post test. Thabet et al., 2005 Palestinian (9–15 years, n = 47 intervention, n = 22 psychoeducation, n = 42 control) Gaza (not reported) Child PTSD Reaction Index, Child Depression Inventory Crisis Intervention: 7 weekly sessions. Free drawing and narrative discussion/ writing of traumatic events, role-play related to conflict. Psychoeducation: 4 sessions of teacher-provided information about the meaning and consequences of trauma, as well as coping strategies No significant effects of intervention were noted. Wolmer et al., 2011 Israeli (8–12 years, n = 754 intervention n = 1152 control) Israel (not reported) Child PTSD Reaction Index (8 items), Stressful life events, Classroom Atmosphere, UCLA PTSD Reaction Index Teacher-delivered intervention, 16 weeks (45 minutes per module) Trauma focused intervention centered around “Adam” who shares experiences, complex feelings, and guides children through activities Children in the intervention group had symptoms that significantly declined over time. When compared to a comparison group (recruited later), children in the intervention group had fewer PTSD symptoms. Wolmer et al., 2013 Jewish Israeli and Palestinian Israeli (n = 1372 at baseline; high attrition) Northern Israel (not reported) Child PTSD Reaction Index (5 items), Stressful life events Teacher-delivered intervention, 16 weeks (45 minutes per module) Trauma focused intervention centered around “Adam” who shares experiences, complex feelings, and guides children through activities Arab children showed the most severe symptoms, which declined to be similar to symptoms in other groups at post-test. 32 L.E . M iller-G ra ff, E .M . C u m m in g s /D evelo p m en ta l R ev iew 4 3 (2 0 17 ) 1 –4 7 ing nature of children’s symptoms in response to the level of violence in their environment, it is difficult to discern intervention effects accurately. Discussion Strong support emerged for the conclusion that exposure to political violence is linked to a range of negative outcomes for children across developmental periods (Abdeen et al., 2008; Boxer et al., 2013; Dubow, Boxer et al., 2010; Dubow, Boxer et al., 2012; Dubow, Huesmann et al., 2012; Haj-Yahia, 2008; Kolltveit et al., 2012; Laufer & Solomon, 2009; Punamäki et al., 2001; Qouta et al., 2007; Qouta et al., 2001; Solomon & Lavi, 2005). Notably, Table 3 provides treatment of the key elements of the re- search design and findings for all of the studies reviewed concerned with youth development, further supporting the extensiveness and archival contribution of the review and analysis of extant research on the Israeli–Palestinian conflict and youth development. Rates of psychopathology are higher in those studies whose data collection time frame was closer to recent escalations in political conflict and/or for samples collected in more highly-exposed regions (e.g., Espié et al., 2009; Kolltveit et al., 2012; Qouta & El Sarraj, 2004; Solomon & Lavi, 2005; Pat-Horenczyk et al., 2013). Comparative studies and an analysis of single-sample studies suggest that rates of exposure and consequent psychopathology are more common and more severe for Palestinian than for Israeli children (7–45% vs 35–75%; e.g., Abdeen et al., 2008; Elbedour et al., 2007; Laufer & Solomon, 2009; Pat-Horenczyk et al., 2009; Solomon & Lavi, 2005) although in specific regions of Israel that are more highly exposed to political violence, PTSD rates are high (44.6%; Pat-Horenczyk et al., 2013). Further, even in the context of similar levels of political violence exposure, Palestinians and Palestinian–Israelis appear to be more vulnerable to mental health problems, suggesting that low social status, discrimination, stigma, and other contex- tual risk factors may put these children at higher risk (Dubow, Huesmann et al., 2012; Schiff et al., 2012). Regarding treatment studies, there is general evidence for the effectiveness of treatment, but very little treatment research has been conducted and the magnitude, duration, and clinical reliabil- ity of change are not yet clearly established. Gaps in basic research and future directions (objective 5) The review of the basic research indicates a growing mindfulness of broad assessments of chil- dren’s social ecology and relevant mediating/moderating factors, which is highly consistent with global theoretical and review work (e.g., Betancourt & Khan, 2008; Dubow, Huesmann et al., 2009; Masten & Narayan, 2012). There are two ways in which this review and broader reviews inform one another. First, there are domains in which this regional research falls short of contemporary theoretical ad- vances in the field, more broadly. Second, there are conflict-specific considerations that are suggested by the empirical literature that have not been fully integrated into psychological literature on chil- dren and political violence, more broadly. Longitudinal evaluations of political violence exposure and child adjustment have been a major priority of international research efforts in the domain of political violence and child adjustment, yet they represent a substantial minority of the designs employed in this region. While this imbalance is not atypical, it inherently limits the ability to fully and robustly evaluate the developmental, social- ecological models that are stipulated in the broader literature. Further, cross-sectional data are inherently limited for several reasons due to context-specific characteristics; namely, the conflict in Israel– Palestine is ongoing and unevenly affects particular communities and geographic locations at different times. For this reason, regular reviews of the literature that help to place research studies in the context of the broader regional chronosystem are important (see, for example, Qouta, Punamäki, & El Sarraj, 2008). This is recognized in much of the literature reviewed here (e.g., Slone & Shoshani, 2014), and it is clear from cross-sectional data that the prevalence of exposure and severity of psychopathology may vary substantially based on the timing of data collection. To date, most longitudinal work in Israel and Palestine has been conducted by Dubow and col- leagues (see Table 1) and Punamäki, Qouta and colleagues (see Table 2). These large-scale studies have been among the first to evaluate influences on child adjustment across the social ecology; because of their longitudinal design, these studies also give important insight into how children are affected by 35L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 political violence across development. To date, however, the measurement methods in longitudinal work in Israel–Palestine have rarely usedmulti-method assessment approaches. As work in this domain progresses, researchers may wish to consider the inclusion of more contemporary multi-method evaluations including biological, observational, and biobehavioral assessments that could serve as a supplement survey data. Specifically, assessments of sleep, cortisol stress response, epigenetic effects, and gene by environment interactions have been shown to be of particular significance in contem- porary research on violence and trauma in other settings (e.g., Boks et al., 2015; Kohrt et al., 2015; Gerhart, Hall, Russ, Canetti, & Hobfoll, 2014). Both cross-sectional and longitudinal studies have illuminated a wide range of possible mediat- ing and moderating factors in the relationship between political violence and adjustment, highlighting the value of the complex and multi-systemic models forwarded in much of the broader review liter- ature. The inclusion of family and community processes is especially relevant in the context of Israel and Palestine given the long-standing nature of the conflict, possible variations in effects across com- munity contexts and the likely role of family processes in mediating or moderating outcomes, and possible intergenerational transmission of trauma. However, very few studies of children reviewed here include robust assessments of parental or family functioning and almost none have collected sub- stantial data on broader contexts of development (i.e., community). Research in this region has also highlighted potential mediating/moderating constructs that are uniquely important to examine in this context. There is emerging evidence of the importance of po- litical engagement and participation, constructs that are especially important to examine in light of social movements such as boycotts, divestments and sanctions (BDS) and with consideration of the political, economic, and psychological disenfranchisement inherent in the occupation of Palestine. Further, the concepts of “power” and “dominance” emerged in a few of the studies reviewed here, and such work should be taken up in more depth – especially considering that power and structure have been heavily analyzed factors in sociological and historical understandings of the conflict. More specific to this review, great variation was evident in the assessment instruments used to assess political violence and psychopathology across settings. Reflecting the highly regional nature of severe violence exposure, many Israeli studies in low-exposed regions evaluate “psychological ex- posure” and other forms of indirect exposure (e.g. Schiff, 2006), while Palestinian assessments tend to assess more direct victimization experiences (e.g., Haj-Yahia, 2008). Similarly, in the calculation of prevalence rates, some Israeli studies use lower cut-offs for PTSD symptoms (e.g., 14–16% exceeding “moderate” cut-offs; Laufer & Solomon, 2009) than do studies with Palestinian populations (e.g., 59% with “severe” or “very severe” range symptoms; Thabet, Abed & Vostanis, 2002). When similar, lower cut-offs are applied in Palestinian samples, rates of “moderate” or higher PTSD symptoms jump to over 80% in some samples (Qouta & El Sarraj, 2004). While this reflects, to some extent, appropriate at- tentiveness to contextual differences in experiences of political violence and their effects by researchers, the wide variation in instrumentation to assess constructs suggests that comparing samples across studies should be undertaken very cautiously. Among other reasons for caution are that quite differ- ent levels of exposure and youth outcomesmay be identified based on the same constructs (i.e., political violence, PTSD), in particular, the use of different instrumentation and cut-offs may mask real and sig- nificant differences between samples in terms of prevalence rates of exposure and psychopathology. In addition to the lack of consistency in measurement, few studies assessing political violence ex- posure have also assessed exposure to violence in other domains. The assessment of polyvictimization is highly important to understanding children’s development and adjustment, and there is substan- tial evidence demonstrating that exposure in one domain is related to exposure in others (Boxer et al., 2013; Cummings et al., 2012; Finkelhor, Ormrod, & Turner, 2007; Graham-Bermann, Castor, Miller, & Howell, 2012; Hamby & Grych, 2013). Polyvictimization, or exposure to multiple types of violence (e.g., political, domestic), is linked to even poorer outcomes for children than is repeated exposure to a single type of victimization (Finkelhor et al., 2007; Graham-Bermann et al., 2012; Margolin, Vickerman, Oliver, & Gordis, 2010). Beyond this, few studies of children exposed to violence in Israel and Palestine have included em- pirical examinations of resilience. This is somewhat surprising given that resilience is regularly examined in the adult research in the region (e.g. Hobfoll, Mancini, Hall, Canetti, & Bonanno, 2011; Hobfoll et al., 2009) and is a major priority in global research on children and political violence (Barber, 2014; Masten 36 L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 & Narayan, 2012; Tol et al., 2013). There has been significant work conducted on the cross-cultural assessment of resilience in children and youth that includes samples of children living in Israel and Palestine (Ungar & Liebenberg, 2011). The instruments and methods that have arisen from this work have yet to be systematically incorporated into research on the effects of political violence on chil- dren and youth (Masten, 2014; Masten & Narayan, 2012). Finally, the vast majority of studies conducted on children exposed to political violence have ex- amined only youth over the age of 8. Although the effects of exposure in middle childhood and adolescence are certainly critical, research on violence exposure in other contexts has demonstrated that children begin to show signs of maladaptation in infancy. Even very young children evidence neg- ative emotional and behavioral reactions to exposure to conflict and violence (Cummings & Davies, 2011). For example, infants exposed to family violence have been found to demonstrate early symp- toms of PTSD (Bogat, DeJonghe, Levendosky, Davidson, & von Eye, 2006). Preschoolers exposed to violence demonstrate higher levels of internalizing and externalizing adjustment problems (Shahinfar, Fox, & Leavitt, 2000) and may also have lower verbal ability and more health problems than non-exposed children (Graham-Bermann, Howell, Miller, Kwek, & Lilly, 2010; Graham-Bermann & Seng, 2005). The dearth of research on violence and early childhood is similarly reflected in treatment research; with almost no evidence-based trauma treatment options for children between 0 and 6. Gaps in treatment research and future directions (objective 5) Treatment research with children exposed to political violence is a very young field of work; much of the research and theory in this domain has been produced in the past 15 years. For example, Barenbaum et al. (2004) in their review of literature from the 1980s and 1990s conclude that there was a great paucity in evidence, with little to suggest specific intervention techniques or formats. Since this time, several important theoretical works and empirical studies of treatment have improved the depth and quality of information to inform care of conflict-affected children. In a review of the literature by Peltonen and Punamäki (2010) of interventions in conflict zones, they highlight that although effectiveness was noted for improving posttraumatic stress symptoms, most interventions failed to comprehensively address the socio-developmental needs of children. Further, they assert that most interventions lack an underlying theoretical model that drives the selection of treatment components. In an overarching service model, Jordans et al. (2010) recognize the impor- tance of ecologically-attuned care. In their model, Jordans et al. (2010) suggest a tiered approach to intervention, whereby initial care is broadly disseminated to the general population to disseminate psychoeducation and programming related to building community resilience. Following this, they suggest that second-tier interventions be focused on at-risk groups with mild distress and then third-tier ser- vices for those requiring more intensive psychological care. In another seminal theoretical model for treatment processes in conflict zones, Miller and Rasmussen (2009) suggest that interventions not only should address the direct effects of war on mental health, but also respond to daily stressors (both war-related and other) that individuals living in conflict zones experience. In sum, all models for care suggest attentiveness to the specific contextual realities of mental health in conflict zones that broaden the scope of intervention from war-related to trauma to a need for interventions that more broadly address the harmful and continuing effects of war on communities, families, and daily life. For themost part, empirical intervention research in Israel and Palestine does not address the breadth of outcomes or systems that have been forwarded in theoretical work. In terms of quantity, there are few intervention studies available to inform general policy regarding children’s care (n = 16). More- over, data from extant research studies are difficult to interpret or generalize becausemany of the samples are limited to a very specific region (e.g., Sadeh, Hen-Gall & Tikotzky, 2008) and treatment gains are generally small to moderate (Gaboulaud et al., 2010; Shechtman & Tanus, 2006; Slone & Shoshani, 2008). Those studies demonstrating stronger impacts of intervention on mental health (Barron, et al., 2013; Berger et al., 2007) typically have not included long term follow-ups, making it difficult to as- certain if gains could be maintained over time. Those studies demonstrating longer-term effects have been conducted only on small samples, to date (Gilboa-Schechtman et al., 2010). Importantly, inter- ventions appear to be more highly efficacious in Israel than in Palestine, which could be the result of the specific treatment methods employed but is also likely indicative of sociopolitical realities inso- 37L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 at random to treatment and control groups, testing manualized programs, conducting fidelity checks to document and ensure program adherence on a consistent basis, and including both short and long- term follow-ups to determine if the program has benefits, and that these benefits last. The “gold standard” practice, however, may conflict with important sociomoral and ethical responsibilities to children and families and may be difficult for already overburdened service organizations to effectively employ. For this reason, we suggest a few considerations in terms of the design and structure of program evaluations: 1 Given that there is sufficient evidence that some programming is effective in this context, head- to-head treatment trial, where one possibly efficacious treatment is tested against another evidence- based treatment, is the most ethically sound research practice. 2 When evaluating intervention programs, measures should be selected in collaboration with com- munity members and organizations to identify the best structure and length of assessments. 3 To the extent possible, interventions should be developed in consultation with and implemented by local constituents. This maximizes the sustainability of mental health interventions and en- hances the likelihood that collaborative relationships will result in well-adapted and designed treatments. 4 Intervention programming and evaluation should carefully consider and integrate the sociopolit- ical contexts of children and families, with the intent of supporting mental health while not undermining, in any way, individuals’ rights and motivations for nonviolent action against injustice. Beyond this, programs should aim to address and ameliorate multiple elements of the social ecology in order to maximize the potential impact. That being said, some elements may be more amenable to change than others. For example, extensive research supports the importance of family function- ing for buffering children from the effects of stress and exposure to violence. Moreover, family functioning is potentially amenable to influence by intervention programs, even in contexts of high, chronic and continuing political violence (e.g., Palestine). Thus, the family would seem to be a logical potential focus for intervention and may be especially important to consider in contexts of low community re- sources, including the schools (e.g., Palestine). Yet the interventions reviewed here have rarely included broader family systems. As such, efforts made to intervene at the family-level and in other social eco- logical contexts, such as community relations and the schools, may be one route of augmenting the currently weak treatment effects noted. It is critical to note that in this context, both parents and chil- dren have had extensive exposure to conflict and violence, and given the intergenerational effects of mental health difficulties (e.g., Palosaari et al., 2013), interventions for children in this context may do well to provide explicit mental health supports for parents above and beyond the typical “parent components” in children’s mental health treatments in Western contexts. Interventions should also be specifically constructed around a theory of change, and the mecha- nisms underlying change should be tested in the evaluation of the impact of the program. Without such model for program building based on a theory of change, limited faith can be placed in the like- lihood of success, or, even in the event of positive program effects, the promise of any evaluation as to why and how (i.e. mediators), or for whom and when (i.e., moderators) the program worked. EST, with a strong basis in tests of explanatory mechanisms for change in Northern Ireland, merits con- sideration as one mechanism that may underlie a model for a theory of change for intervention that has empirical support in other contexts (e.g., Miller-Graff, Cummings, & Bergman, 2016). In addition, consistent with a social ecological perspective on intervention, there are promising bases for provid- ing contexts for increasing children’s sense of safety and security in other social ecological contexts, such communities, even in the context of on-going political violence, although the elements of such approaches in Israel and Palestine remain to be specifically developed. In sum, programs should ideally be guided by the translational of empirical findings of basic research, keeping theories of changemodels firmly in mind, and test for mechanisms of change as well as short- and long-term effects of inter- ventions onmultiple domains of children adjustment and well-being, with the key elements to consider outlined elsewhere in this review. Finally, in addition to working toward changing contexts of political violence, programs may also consider proven elements toward supporting individual functioning – another key element of a social ecological model. In the face of stress and trauma, cognitive behavioral techniques may be of some 40 L.E. Miller-Graff, E.M. Cummings /Developmental Review 43 (2017) 1–47 use. Although many of the CBT programs evaluated in Palestine to date have not shown positive effects (e.g., Punamäki, Peltonen, Diab, & Qouta, 2014; Qouta et al., 2012), this may be due to the use of group- based rather than individual intervention, the latter of which has shown much more promise in the context of serious and chronic violence (e.g., O’Callaghan, McMullen, Shannon, Rafferty, & Black, 2013; Miller-Graff & Campion, 2016). For the most part, however, intervention research has primarily con- sidered theories of change and treatment effectiveness in samples where traumatic exposures have significantly lessened or have ceased entirely. Given that violence in this setting, especially for Pal- estinians, is chronic and serious, more theoretical work is necessary to conceptualize how the “remediation” of cognitive and emotional processes might differ in this context. 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