Great Muslim Scholars:

Abu Qasim Al- Zahrawi (Albucasis) 936-1013

Ibn Sina (Avicenna) 980-1037

Medical and Social Issues:

DOMESTIC VIOLENCE Role of Physicians

Effect of Terrorism  on Children

Abu Qasim Al- Zahrawi

Albucasis

The Father of the Surgery

(936-1013)

M. Basheer Ahmed M.D.

Published in Journal of the Tarrant County Medical Society in February 2009

During 8^th to 15^th century when Europe was in dark ages a great civilization was flourishing in Middle-East and southern part of Europe under Muslim empire. It was from Muslim Spain, that the era of modern civilization dawned over the whole Europe. Cordoba was the capital of Spain in 9^th century which became the center of learning. The city had several teaching institutions and had the largest collection of books in the then known world which included the original works of Aristotle and other great philosophers and scholars. European scholars flocked to the universities in Baghdad and Cordoba and returned home to spread the knowledge they gained. During this period a great surgeon who is truly recognized as father of surgery was born in Cordoba. 

Abu Qasim ibn al-Zahrawi, also known in the West as Abul Casis, was born in the town of Al Zahra located six miles northwest of Cordoba, Spain. His ancestors were Arabs who settled in Spain in the 8^th century. He lived most of his life in Cordoba where he received his education. He taught and practiced medicine and surgery in Cordoba and became the physician of Caliph. The street where he lived is named after him (Calle Abucasis) and his house has been preserved by the Spanish government. He is considered as father of surgery as he became famous throughout Europe for teaching new methods of surgery and inventing several instruments which were used in most of Europe until 17^th - 18^th century. In addition to his knowledge of medicine and surgery he was very skilled in the use of simple and compound remedies and thus he was also known as the “Pharmacist Surgeon”.  He wrote extensively on cardiac drugs, emetics, laxatives and cosmetology. Translation of Al Zahrawi’s work “Liber Servitoris” provide readers an explanation of preparing simple and compound complex drugs that generally used in those days¹.

His greatest contribution to the history of medicine is his famous book “Kitab-al-Tasrif”, a thirty volume encyclopedia on medicine which is based on his personal experiences in practice of medicine for 50 years. It was first published in the year 1000 and it covered a broad range of topics from dentistry to child birth. He had a sound knowledge and understanding of relevance of anatomy in surgical procedures. In the introduction of his book Al Tasrif, Zahrawi stated that learning the art of surgery is lengthy and a good practice in surgery required sound knowledge of anatomy. “He who devoted himself to surgery must be versed in the science of anatomy.”² However the anatomical study of human body was problematic because it required dissection and a number of religious scholars apposed dissection of human body since it implied mutilation and disrespect of the diseased person. In spite of this opposition Al Zahrawi and other scholars made frequent references to dissection of both animal and human body³. This shows an intellectual open mindedness in earlier Islamic time. During this period of Islamic history the Muslim Scientist created a non-dogmatic atmosphere that encouraged people to debate, share ideas and seek new knowledge and examining evidence⁴.

The first two volumes of his book Al-Tasrif were primarily devoted to surgery. The first dealt with cautery which was used extensively in Arabia and it also contained a detailed description of the use of various instruments. There was also an extensive description of incisions, perforations, wounds, and the healing process. Al Zahrawi had made several useful additions to the art of surgery. He described various types of thread (including catgut) for stitching of wounds. Al Zahrawi’s use of catgut for internal stitching is still practiced in modern surgery. He pointed out for the first time the dangers associated with amputation above knee and above elbow. He is one of the first physicians who explained hemorrhage which cannot be easily controlled, the disease known today as hemophilia. He also pointed out the hereditary nature of this disease.  

 The second volume of Al-Tasrif was devoted to the description of lithotrity, lithotomy, fractures, dislocations, and special treatment of fracture of pelvis. He wrote extensively about injuries of bones and joints, fractures of the nasal bones and the vertebrae. In fact Kocher’s method for fixing a dislocated shoulder was explained by Al Zahrawi long before Kocher. He also described tonsillectomy and tracheotomy operations he had performed⁴.

The third volume described detailed procedures of performing ophthalmic operations including “cataract”. Al Zahrawi was also an expert dental surgeon. He discussed the non-aligned teeth and showed a way to correct them. He also developed technique of replacing defective teeth.

105 chapters were devoted towards describing the details of various operative procedures including amputation, and the crushing of bladder stones. He used the grooved probe for dislodging urethral obstructions and invented sponge tipped probe for dislodging foreign particles from the gullet. He also used a syringe for irrigation of the bladder and the cleaning of the ear. Al Zahrawi also wrote about obstetrics and described several instruments used for delivery. He was the first to describe the welcher position in obstetrics. His book contains the pictures of gynecological instruments used in the 10^th century e.g. vaginal speculum and instruments to perform cranioctomy for bringing out the dead fetus⁵. He was the first to write about ectopic pregnancy.

He also treated hydrocephalus in young children by making a small hole in the skull by means of cauterization to extract the fluid. The last volume of his encyclopedic book Al-Tasrif contained a description of 200 surgical instruments. The majority of these instruments were devised, designed, and used by Al Zahrawi himself. ^6,7,8 He included illustrations of the surgical instruments. These figures probably were the first of their kind that survived till now and they constituted a unique contribution to the history of surgery.

He was considered one of the early leading “plastic surgeon” as he performed many plastic surgery procedures. In the 11th chapter of volume 30 of his book he put many principles in that surgical field⁹.

Al Zahrawi’s writings were translated into Latin and were used as the standard book of medicine in Europe for several centuries. His writings on anatomy and surgery raised him to the level of Hippocrates and Galen. In fact his work represented the first step of surgery as an independent specialty away from medicine, grounded on the knowledge of anatomy. Al Tasrif became famous in the universities of Europe in the middle ages and was the chief reference work for surgery in the universities of Italy and France.¹⁰

Al-Zahrawi was the first in Muslim Spain to establish a large medical school. He was very meticulous about maintaining a high standard of education and medical ethics. Al Zahrawi emphasized the importance of a good doctor patient relationship insuring the safety and trust of the patient irrespective of their social status. Al Zahrawi was one of the first scholars in Islam to promote nursing and encouraged women to become midwives. Because of his enthusiasm and devotion, good hospitals and nursing care was enhanced in Andalusia (Spain)⁹.

Guy de Chauliac, a fourteenth century French surgeon, quoted Al-Tasrif over 200 times in his book, “The Great Surgery.” Pietro Argallata, a fifteenth century European surgeon, says of him, “Without doubt he was the chief of all surgeons.” Jaques Delechamps, another sixteenth century French surgeon, made extensive use of Al Zahrawi’s writings in his elaborate commentary, confirming the tremendous contributions of Al Zahrawi in the field of surgery. Al – Zahrawi’s work was initially translated in Latin by Gerard of Cremona in 1187 and since then for the next 5 centuries it was translated in Hebrew, French, English and other European languages. After the introduction of printing press, a good number of Arab writings were published in Latin Translation. Quite of few of these books passed through many editions in a very short period of time. Many of these translated books are still available in the libraries in Berlin, London, Paris and Washington D.C¹¹.  These additions no doubt constituent a proof as to the wide readers of these books through out the world.

Dr. Basheer Ahmed is the Former Professor of Psychiatry, South Western Medical School, Dallas, Texas and has been in private practice of psychiatry in Fort Worth, Texas since 1980. He is the founder and chairman of Muslim Community Center for Human Services, North Texas which provides free medical and social services to indigent residents in this area. He recently edited two books “Muslim Contribution to World Civilization” and “The Islamic Intellectual Heritage and its Impact on the West” He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

REFERENCES

1: Levey M. (1973), Early Arabic Pharmacology, E. J. Brill, Leiden.

2:  Jones, PM. “Medieval medical miniatures.” London: The British Library, in association with

            The Wellcome Institute for the History of Medicine; 1984 – Page 27-29

3: Savage-Smith E. “Attitude toward dissection in medieval Islam.” J Hist Med Allied Sci.

            1995;50: 67-110

4: Hehmeyer, I. & Khan, A. “Islam’s Forgotten Contribution to Medical Science” Canadian

            Medical Association Journal 176. 2007

5: Gimovsky, M.L., Soo Han, J “Reducing the medico legal risk of vacuum extraction” OBG

            management Volume 19 No. 6, June 2007, page 84

6: Lunde, Paul. “Science in Al Andalus” Published in Science: The Islamic Legacy. Aramco –

            Washington D.C. 1988, page 21-26

7: Azmi, A.A., “Contribution of Muslim Physicians in the Middle Ages”, Hamdard Vol. XXIX

            1-2 1988 – Hamdard Publications, Karachi, Pakistan

8: Ashoor, A.Z. “Muslim Medical Scholars and their Work” Islamic World Medical Journal.

 January 1984, Pages 49-50

9: Al Ghazal S. K. “Zahrawi and Plastic Surgery”, ArabMed Journal, Issue 2(12);  2002.

10: Hayek, Simon. “How Al- Zahrawi Reached the Occident” Islamic World Medical Journal.

            February 1984, Page 49-52

11: Hamarneh, Sami K. “Vistas of Arabic Healing Arts in Theory and Practice”, Hamdard

XXXII No. 3 September 1989, Page 3-54 16-18.

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 Ibn Sina (Avicenna) 980-1037

A Great Physician and Scholar of the Medieval Era

M. Basheer Ahmed, M.D.

Published in Journal of the Tarrant County Medical Society in March 2008

There is no doubt that Western civilization has made invaluable contributions to the development of modern sciences; however, scientific progress did not start suddenly, exclusively, in Europe, or appear out of nowhere in the 16th century. European and American history acknowledges the work and scientific advancement done by Greek and Roman scholars until the 3rd century A.D. It picks up again in 1500 A.D. at the beginning of the Renaissance.

Did nothing happen in the sciences between 300 and 1500 A.D.? Very little is mentioned about the history of social, political or scientific development in traditional history texts. Historian Harold J. Morowitz described this phenomenon as "The History¹s Black Hole." He asserts that the given impression is that the Renaissance arose, Phoenix-like, from ashes smoldering for a millennium of the classical age of Greek and Rome.¹ In fact, the period between 300-1500 A.D. is regarded as the Dark Ages for Europe, as scientific progress there remained dormant. Virtually no progress was made especially in the field of medicine. During this time, the powerful and authoritarian Roman Catholic Church viewed care of the soul as far more important than care of the body; thus, actual treatment of physical illness was little valued. Prayers became the primary mode of treatment. The study of disease and patient care were neglected. Any knowledge of medicine was limited to studying the writings of ancient physicians; and, consequently, the practice of surgery was almost abandoned.²

   In another part of the world, the Islamic civilization was emerging. During the 6th and 7th centuries, medicine was the first of the Greek sciences to be studied in depth by Islamic scholars. After Plato¹s academy was closed in 529 A.D., some European scholars, including physicians, found refuge in Jundeshapur, the old capital of Persia, in what is now known as the Middle East. Jundeshapur became part of the Muslim world in 636 A.D. and, for the next two centuries, took its place as one of the greatest centers of medical teaching. Muslim physicians studied Hippocrates, Galen and other Greek physicians. They were also exposed to the acquired medical knowledge of Roman, Indian and Chinese scholars. These physicians translated all the great texts into Arabic, preserving this body of knowledge from extinction. The medical works of Galen and Hippocrates was reintroduced to Europe through Latin translation of the great Arabic medical classics of Hippocrates and Galen, along with the original research and scientific study of Muslim scholars.

   These early Muslim physicians recognized that the knowledge of medicine included studying the human body, diagnosing ailments and treating them with appropriate medications as well as surgical interventions. They established hospitals, medical schools and written medical textbooks. These books were widely used in Europe until the 16th century. Muslim physicians made accurate diagnoses of a variety of illnesses such as plague, diabetes, gout, epilepsy, cancer, various infections and surgical disorders. They set down the principles of observation, clinical investigations and drug trials. They mastered surgical skills and devised new tools, filled teeth with gold, introduced optics and described in detail the fundamentals of diet and hygiene, many of which are still valid today.

   Among the well-known Muslim physicians, the most famous is Ibn Sina (Avicenna). Abu Ali Hussain Ibn Sina was born in the Persian province of Balk (now in Afghanistan) in 980 A.D., and moved to Bukhara (now Uzbekistan) during childhood. Ibn Sina was the most brilliant medical scholar, philosopher and educator in the world at the beginning of second millennium. He is also called Al-Sheik -Al Rais (The Prince of All Learning), because of his vast knowledge, which included medicine as well as many other disciplines such as mathematics, philosophy, logic and religion. He did original research and contributed to the development of all sciences. Through his efforts, medicine recorded an unprecedented progress.

   Ibn Sina would be considered an intellectual prodigy by any standard. By the age of 10, he had mastered the Arabic language and the Qur¹an.  By age 14, he had studied philosophy, mathematics, astronomy and the Greek language. He examined Aristotle¹s philosophy and logic, Porphyry¹s Isagoge, Euclid and Ptolemy¹s Astronomy and other sciences. At age 17, he learned medicine, and within a few years, his reputation as an expert physician was so well-established that he was appointed as King¹s physician. He traveled to several large cities in the region, including Jargon, Ray, Hamadan, Isfahan (Iran) and Baghdad.  Ibn Sina started writing at the age of 21 and wrote more than 200 books on philosophy, astronomy, theology and medicine. He excelled in the knowledge of logic and philosophy, and reintroduced Aristotle to Europe through his writings.  
   
Ibn Sina¹s most significant contribution to medical science was his famous book Al-Qanoon Fil Tibb ("The Canon of Avicenna"). It was the pre-eminent medical encyclopedia of that time and remained a standard textbook of medicine for the next 700 years.  In addition to bringing together all of the current available knowledge, Ibn Sina made original contributions to this five-volume text. The first volume deals with anatomy, physiology and pathology, with emphasis on the importance of dissection of the human body. The second volume describes the general principles of treatment, and pharmacology. The third and fourth volumes consist of diseases of all organs of the body, special pathology of fevers, and signs and symptoms of known diseases.  The fifth volume describes a disease that starts in one part of the body but subsequently affects several parts of the body.
 
       Unique for its time, Ibn Sina¹s work indeed gave a different perspective and clarified the knowledge of medicine. He made a comprehensive attempt at collecting, systematizing, as well as updating, the data with personal observations and original research. The fragmentary and unorganized Greco-Roman medical literature that had been translated into Arabic was reorganized in order to produce a coherent and orderly medical system. The encyclopedic work of Ibn Sina included the entire medical knowledge available from ancient to the most current sources. Due to Ibn Sina's systematic approach for perfection and its intrinsic value, the Qanoon (Canon) superseded the work of Galen and remained superior for six centuries.

   Ibn Sina was the first physician to describe guinea worm infestation and anthrax.  He was the first physician to discuss the theory that small organisms may be responsible for infectious diseases, 1000 years ago,  and advocated the use of broad mold organisms in the treatment of non-responsive open wounds.  He described trigemmal neuralgia and facial paralysis of central and peripheral types. One important, original contribution included his recognition of the contagious nature of phthisis and tuberculosis; the distribution of diseases by water and soil; and, the interaction between psychology and health. Ibn Sina wrote separate chapters on cardiac drugs for the elderly. He also discussed the treatment of anxiety, depression and melancholia.

   The Qanoon was translated into Latin and Hebrew.  About 30 editions were published in Europe.  The last Italian edition was published in Rome in 1593.  Until the 17th century, half of the medical school curriculum in Islamic and European countries was based on Ibn Sina¹s book Al-Qanoon³.

   Other noteworthy books by Ibn Sina include Isharat, focusing on philosophy and logic. He contended that logic does not discover truth but helps man make best use of his qualities and prevents him from making wrong decisions. In another, Kitab Al-Shifa ( A Book of Healing), he described a detailed method of preparation of medications (simple and compound), medical ethics and philosophy. Ibn Sina writes his observations and encourages discussion on Platonic philosophy and Islamic theology.

   Sir William Osler, the father of modern medicine, sums up Ibn Sina¹s personality in this way:  "We cannot understand the sway exercised by Ibn Sina for three or four centuries mentally to live and move in the medieval mind is not given to many and the knowledge most of us have of Rais (The Chief) is a third or fourth hand."  Students like Carre de Vaux were eloquent over the precocity of Ibn Sina's talents, the quickness and loftiness of his intellect, the clarity and force of his thought, the multiplicity and extent of his work, the impetuosity and variety of his passion. Regarded as a resume and symbol of all human activities, he stands out as one of the great personalities in a great civilization His enthusiastic biographer, Carre de Vaux, does not hesitate to say, "Netemps, ne presentment plus de figure."  Translated, this means, "Never time will present a comparable figure since encyclopedic knowledge no longer exists." ⁴

   A fitting closing to this article is Ibn Sina's opening of the Qanoon:
"Medicine is a science from which one learns the status of human body with respect to what is healthy and what is not, in order to preserve good health when it exists and restore it when it is lacking."³
   
BIBLIOGRAPHY

1. Morowitz, H.J. “History’s Black Hole” – hospital practice, May 1992, p.25-31
2. Tschanz, David "Arabs Roots of European Medicine" Saudi Aramco World, May/June 1997, Volume 48 No.3
3. Savage, Smith E. "Islamic Culture and Medical Arts" National Library of Medicine Bethesda MD, 1994
4. Osler, W. "The Principle and Practise of Medicine"  New York 1892

BIOGRAPHY of the AUTHOR
M. Basheer Ahmed, M.D., was born in Hyderabad (DN), India. He obtained his medical degree from Dow Medical College, Karachi, and completed his postgraduate studies at Glasgow University, Scotland. He is a Board Certified Psychiatrist and a distinguished life fellow of the American Psychiatric Association. He was assistant professor at Albert Einstein College of Medicine, NY, and Prof. of Psychiatry at Southwestern Medical School, Dallas, TX. He recently retired from Private Practice in Fort Worth.
Dr. Ahmed is the past president of the Islamic Medical Association, North America, He is the Vice President of Institute of Medieval and Post Medieval Studies. He edited a book, "Muslim Contribution to World Civilization," which was published in 2005.

Dr. Ahmed is the founder and chairman of Muslim Community Center for Human Services, which is a medical and social service organization, helping indigent residing in the Dallas/Fort Worth area. He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

DOMESTIC VIOLENCE

Responsibilities of Physicians, Health Care Providers, and Community Leaders

M. Basheer Ahmed, M.D.

Published in Journal of the Tarrant County Medical Society in May 2008

Summary:

·        The incidence of Domestic Violence is much higher than reported and every physician must be knowledgeable about the dynamics of Domestic Violence.

·        Physicians must screen all female patients over age 18 for signs of Domestic Violence. Patients are usually reluctant to share the information and physician needs to ask direct questions especially to patients, who have unexplained injury or multiple vague symptoms – “Have you experienced Violence at the hand of your spouse or partner?”

·        Physicians must be aware of community resources to which they can refer the patients. (See Appendix II)

 ·        Women ultimately make the decision as to when there are ready to leave the relationship. Physician must be compassionate and give a appropriate advice and make them aware of the safety plan and necessary information about the resources in the community.

(Ref: Diagnoses and Treatment guidelines on Domestic Violence- American Medical Association)

Four million women are assaulted each year in the U.S.A.¹ 8-12 million women are at risk of being abused by their current or ex-spouse.  Every 15 seconds, a women somewhere in the U.S. is beaten in her home.  Violence is the number one public health risk to adult women and it is a leading cause of injuries to women ages 15-44.  It is more common than accidents and cancer.  About 20% of women visit the ER for symptoms of an ongoing abuse.² In Texas, 11,983 women and 17,619 children in abusive relationships received shelter during 2004.³ The US economic burden exceeds $12 billion annually for medical treatment, shelters, police, court time, foster care, sick leave, and nonproductivity.⁴ 

            Domestic violence is a universal problem.  All ethnic, religious, racial and age groups are affected.  Economic and educational levels do not alter the incidents.  There are known cases of abuser who are prominent and successful members of the society.  In some ways, women of high echelon of society are at greater risk as they often maintain silence to avoid embarrassment.  It may also be less evident among the affluent because they can find and afford private physicians, counselors, attorneys and living arrangements.  Individuals with limited financial resources or supporting relatives turn to more public agencies for help. 

The Cycle of Violence – The husband hits the wife, she neglects this as a one-time occurrence, he hits her again, and the behavior continues. She temporary moves to a friend’s house. He repetitively calls, apologizes for the behavior, and asks her to return. She returns home, things are better for a few days. However the pattern of abuse recurs. The threat and the mild abuse turns into a severe blow in the face and bleeding, and she fears for her life. Now she leaves home and goes to sister’s house with the children. She is in a dilemma whether to report or not. If she reports, he will be in jail resulting in a shame, guilt, loss of income, and possibly more reprisals. She worries about support for the children and concerned about the limited resources. She gets very little support from her family and/or religious institutions. Many women go through this scenario and face the most serious difficulties in making decisions. Many years ago, I have seen an attorney’s wife, who had to make this difficult decision as she has to give up a comfortable standard of life and had to face serious difficulty in coping with economic hardship as she gave up her husband whom she had been married to for 15 years, due to persistent physical abuse. She had to spend several months in a shelter before settling down in the community after getting a modest paying job.

Dynamics of Abusive Relationship - Although there are rare cases of women who assault their husbands, by & large spouse abuse occurs because men batter women and getaway with it.  No single theory for why men show such an aggressive behavior is confirmed.  There are sex-linked differences associating aggression & male gender.  Abusive men come from a variety of backgrounds, religions, races and occupations.  Rigid sex role stereotype are pervasive, as abusive men attempt to place their partners in a submissive role.  The abusive behavior is a learned behavior, which is acquired through life experiences in one’s family of origin and through the observation of society at large.  The abusers believe that they have the right to control others behaviors and this concept may be reinforced by the religious and cultural beliefs that the wife should be obedient and subservient.  Peer group approval and cultural practices also come to play a role in this behavior reinforcement. 

Consequences of violence on victims - Domestic violence does not end until outside intervention takes place.  Battered women seldom complain and are hesitant to seek help.  As a result of this, they suffer from a variety of physical and emotional symptoms.  They experience vague somatic symptoms, backache, headache and gastrointestinal symptoms, sleep disturbance and nightmares. They become anxious and nervous due to their husband’s unpredictable behavior.  They develop low self esteem, low self confidence and become socially isolated.  They gradually drift away from family and friends using the excuse that they are busy.  They feel powerless, frightened and extremely dependent. They have too much anger and hostility, but they suppress these emotions. They experience difficulty in communicating and developing any trustful relationship.  Most victims develop depression and experience suicidal ideas due to persistent hopelessness.

Even after separating and divorcing, some of these symptoms continue for a long period of time.

Responsibilities of Physician and other Health Care providers:  On many occasions, physicians fail to recognize an obvious abuse.  The major factor is their lack of awareness. All physicians, especially family physicians, internists, psychiatrists, ObGyn specialists, and emergency room physicians come across frequently the victims of Domestic Violence. While some victims come in with obvious broken bones and contusions, many others may be presented with multiple vague physical complaints.  Physician may be treating the patient symptomatically or patient is diagnosed as depressed and anxious and may be treated with antidepressant and anti-anxiety agents.  Unless the clinician keeps in mind the possibility of Domestic Violence, the diagnosis may be missed.  Victims of abuse seldom reveal or volunteer the information due to shame, humiliation and denial.  They often have difficulty in developing trustful relationship.  They are convinced that what ever is happening, it is their fault and they need psychological treatment.  Unfortunately the victim remains in a dangerous situation while under the care of a physician, if the problem is not recognized early.  Similarly, children who are traumatized from living in a home with domestic violence are often treated for behavioral problem and depression without exploring in depth the home environment.  Children are very frightened and most often unable to express the reason for their mental anguish.⁵

Diagnostic Guidelines for clinicians:  There are no specific signs and symptoms in victim of violence.  Even after acute episode of domestic violence, only 23% of the victims’ visiting the ER have injury related complaints.⁶  They may present with obvious injuries or bruises, lacerations, or fractures, injuries to the head, neck, chest and breast. The prevalence of battering during pregnancy is about 6%.⁷ Pregnant women may be presented with the above-mentioned injuries.  Victims of abuse manifest a variety of psychological problems including anxiety, depression and suicidal ideation.  Some women may suffer from insomnia, eating disturbance, chronic pain, vague somatic symptoms and sexual dysfunction.  Low self-esteem, low self-confidence and minimization of abuse by denial and self blame are also prevalent.  All clinicians must be familiar with this problem and should routinely screen all patients for abuse.  Suspect domestic abuse if the patient has unexplained injuries, but denies any abuse.  The patient may avoid eye contact and seems more agitated if asked about bruises.  Repeated visits to the ER with vague somatic complains, pregnant women with bleeding or miscarriages, symptoms of high anxiety, depression, and suicidal ideation should also raise suspiciousness of abuse.  Be alert if a spouse accompanies the patient and insists on staying close to her.

Given the high prevalence of domestic violence in the acute care setting, the reluctance of women to volunteer information about abuse and the difficulty in identifying abused patients, it is recommended that suspected patients should be screened for domestic violence by explicit questions.  This questioning must take place without the presence of victims’ partner.⁸ 

The following are some of the examples of questions one must ask:

Did someone hurt you?  Are you in a relationship in which you felt you are badly treated?  Are you ever afraid at home?  Does your spouse threaten you?  Does your spouse destroy property?  Does your spouse force you to have sex with him?  Does your spouse prevent you from leaving the house?  Seeing friends?  Getting a job or continuing your education?  Does your spouse control your behavior?  What happens when you have a fight?  Has your spouse ever hit, pushed, shoved, slapped or choked you?  Have you ever been hit while pregnant?  Sometimes people feel depressed and suicidal when one in their life tries to control them.  Do you feel safe going home? 

Breaking a relationship is not easy and therefore clinicians must reassure that help is available. Clinicians must also show support and understanding to gain the confidence and trust of victims of abuse.⁹ In standards issued by the joint commission on Accreditation of Health Care Organization, JCAHO, the phenomenon of victims’ typical reluctance or inability to initiate discussion of abuse is well documented.  Full knowledge of abuse is necessary to provide proper medical care.¹⁰ If a clinician gets negative response to his inquiries but the abuse is suspected, physician should ask explicit questions and give the reading material about Domestic Violence and “Safety Plan brochures” available from Attorney General’s Office of crime victim’s compensation.¹¹

Documentation - Medical records are the only documents, which contain description of the emotional, and physical abuse therefore such documents must be comprehensive.  These should include the relevant facts including the use of weapons and any injuries resulted from the use or threatened use.  Such records are critical for legal actions.¹² Complete medical record may also alleviate the need for health professionals in testifying in court.  In documenting injuries, body maps should be used.  Emergency room physicians must be over cautious when evaluating female patients with injuries.  They should note inconsistencies between possible causes and explanation of injury if patient will not confirm the abuse.

 A physician is negligent if the standard of care is not employed based on what he/she knew or should have known about the patient.  Clinicians cannot avoid liability by failing to conduct universal screening or respond in accordance with the standard of care.  Effective risk management should include an understanding of legal and ethical standards, clear documentation and competent treatment and referral practices.¹³

Many physicians do not like to get involved, they feel it is not in their area of expertise and they are hesitant to accept responsibility for referral to the appropriate agency.¹⁴ The lack of knowledge and sometimes the lack of available resources are also a major hindrance.  Many physicians have difficulty in dealing with the feelings and they have very little time or patience to listen and explore the feelings.  Another area of concern is the medico-legal aspect. 

 Texas Law (Section 91.003 of the Family Code) requires physicians to provide safety and shelter information to patients with injuries believed to be caused by violence in the family and to document giving these materials in the patient's medical record. Some states mandate the reporting of suspected family violence cases. However, Texas has no such requirement unless the victim is a child, elderly, or disabled. These cases must be reported to Child or Adult Protective Services.¹⁵

 Safety Plan: In suspected cases physician must advise about the safety plan. The victim of Domestic Violence should share the information with a trusted friend or relative, must save money for emergency and keep all the documents such as driving license, passport, birth certificate, school record and insurance paper. She must have all the emergency numbers easily available.

 Domestic violence is a crime. It is not a private family matter. If community leaders, health care professionals and community at large are not aware and involved, women will remain in the victims’ role for many years.

 APPENDIX I

Texas State Law, Family Code Section 91.003

A medical professional who treats a person for injuries that the medical professional has reason to believe were caused by family violence shall:

(1) Immediately provide the person with information regarding the nearest family violence shelter center;

(2) Document in the person's medical file:

      (A) The fact that the person received the information provided under Subdivision (1, above), and

      (B) The reasons for the medical professional's belief that the person's injuries were caused by family violence; and

(3)  Give the person written notice in substantially the following form, complete with the required information, in both English and Spanish:

"It is a crime for any person to cause you physical injury or harm even if that person is a member or former member of your family or household.

 APPENDIX II

 Community Resources:

REFERENCES

1. Flit Craft A.H., Hadley S.M., Hendricks, Mathews M.K. et el Diagnostic & treatment Guidelines on Domestic Violence, American Medical Association, Chicago, 244, 1992.

2. U.S. Dept. of Justice “Violence related injuries treated in Hospital emergency dept.”, August 1997.

3. Texas Health and Human Services Commission, Integrated Tracking System, 1993-2004 Annual Data from the Family Violence Program, spreadsheet report. (Point of contact: Dr. Desai at Texas HHS, [512] 206-5040. Data reported directly from shelters throughout the state.)

4. World Health Organization, Injuries and Violence Prevention. The economic dimensions of interpersonal violence. Available at: http://www.who.int/violence_injury_prevention/publications/violence/economic_dimensions/en. Accessed June 4, 2006.

5. Buel, S., Reimer, C. “Recommended treatment guidelines for psychiatrists, intervention with domestic violence”, Texas Society of Psychiatric Physician Newsletter, Jan. 2001.

6. Stark E., Flitcraft A., Frazier W., “Medicine and Patriarchal Violence:  The social construction of a private event”, Int. J Health Serv., 9:461-493, 1979

7. Hillard P., “Physical abuse in pregnancy”, Obstetrics and Gynecology, 66:185-90, 1988

8. Sisley A., Jacobs L., Poole G. et el “Violence in America: a public health crisis”  Domestic Violence, The Journal of Trauma, injury, infection and Critical Care 46:6, 1105-1112, 1999.

9. “Break the silence, begin the cure” Iowa Medicine, Domestic Violence issue, Jan. 1995.

10. Giant Commission on Accreditation of Health care organizations: Comprehensive Accreditation manuals for hospitals (1997), Update 3 PE 10, PE 34.

11. Buel, S. “Family Violence, How you can improve medical interventions with victims”, Texas Prosecutor General, Jan. – Feb., 1998.

12. Hyman, A.  “Domestic Violence – Legal Issues for health care practitioners and institutions”, JAMA, May 1996:3 – July 1996:101-105.

13. America Psychological Association, Professional, Ethical and Legal Issues concerning interpersonal violence, mal treatment and related trauma, 1997, 9-12.

14. Sugg N.K., Inui T., “Primary care physician’s response to Domestic Violence in Opening Pandora’s Box” JAMA, 267:65-68, 1992

15. Schindeler-Trachta, R. E., and Schneider, F. D. “Interpersonal Violence in Texas  - A Physicians Role.” Texas Medicine January 2007.

M. Basheer Ahmed, M.D., was born in Hyderabad (DN), India. He obtained his medical degree from Dow Medical College, Karachi, and completed his postgraduate studies at Glasgow University, Scotland. He is a Board Certified Psychiatrist and a distinguished life fellow of the American Psychiatric Association. He was assistant professor at Albert Einstein College of Medicine, NY, and Prof. of Psychiatry at Southwestern Medical School, Dallas, TX, and UNT Health Science Center Fort Worth. He recently retired from Private Practice in Fort Worth.

 Dr. Ahmed is the past president of the Islamic Medical Association, North America, He is the Vice President of Institute of Medieval and Post Medieval Studies. He edited a book, "Muslim Contribution to World Civilization," which was published in 2005 and he recently edited another book on “The Islamic Intellectual Heritage and Its Impact on the West.” (2008)

 Dr. Ahmed is the founder and chairman of Muslim Community Center for Human Services, which is a medical and social service organization, helping indigent residing in the Dallas/Fort Worth area. He is program Chairman for the Second Regional Conference on “Domestic Violence – Cross Cultural Perspective,”  jointly sponsored by MCC for Human Services and School of Social Work, University of Texas, Arlington.

He can be reached at This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Effects of Terrorism on Children

Psychosocial Biological Understanding

M. Basheer Ahmed, M.D.

Published in Journal of the Islamic Medical Association in May 2007

Many children are exposed to trauma and life-threatening situations. During the last few decades, thousands of children have been exposed to terrorism. No child is immune to the traumatic effects of terrorism whether they are in Oklahoma, New York, Bosnia, Israel, Palestine, Iraq, Lebanon, Rwanda, Kashmir, or Darfur.

Millions of children of the world learn about terrorist acts through watching television but thousands of unfortunate Muslim children in Iraq and Palestine watch the terror on a daily basis and have first hand experience with severe and traumatic incidents. Children saw bombs destroying buildings killing scores of women and children recently in Lebanon in July and August of 2006. The experience of the severe trauma and long term consequences of these atrocities in children are rarely reported in the media, as if these unfortunate children who did not die during the terrorist act, do not exist.

Who can shield these children from such horror, and who speaks for their psychological trauma and well being? Many children end up in hospitals with limited facilities for physical care with absolutely no mental health services or psychological support. Thousands of children end up in refugee camps and shelters with limited resources. Food and medicine remain the top priorities in the affected area. Meanwhile, these traumatized children's emotional health is neglected and they live with fear, apprehension, and anger for years to come.

There are no scientific reports published on the effect of terrorism on the children of Iraq. Few reports were published on the effect of terrorism on Palestinian children. Several reports were published on the effects of the terrorist bombing of the Federal Building in Oklahoma City and the World Trade Center in New York. Most of the reports discuss the effect of acts of terrorism when children watch the death and destruction on television. However, there is a general consensus that the disasters in which harm is inflicted intentionally such as terrorism on civilians are associated with higher levels of distress.¹  

Terrorism causes psychological trauma that results in helplessness in the face of intolerable danger and anxiety. Most of the children will suffer from post-traumatic stress disorder which affects the cognition, emotions, interpersonal relations, and personality development. The most common effect is an enduring sense of pessimism with depression and suicidal ideations. The symptoms of depression and anger are much higher in the children who more frequently experience terror, as in Palestine and Iraq. On average, every Palestinian child has witnessed about ten traumatic incidents. The traumatized children show a range of symptoms including insomnia, nightmares, hyper vigilance, and severe agitation ². Children with adverse stress reactions and behavioral symptoms for longer than one month may be at increased risk of developing PTSD or violent and delinquent behavior later in life ^3,4

This article will summarize the research work on diagnostic criteria for PTSD in children, and adolescents and the neurobiology of early life stresses, and post-traumatic disorders. It will also examine the short-term and long-term effect of exposure to terrorism in children and some treatment modalities.

            Stress of trauma is experienced when an individual (a child or adult) is confronted with a situation that is personally threatening to self or others.  Some of these children may grow up normally with adequate coping mechanisms, but the majority may develop long-term consequences of these early-life stresses resulting in deep-seated psychological problems if early therapeutic intervention is not provided.

The diagnostic criterioa for Acute Stress Disorder and Post Traumatic Stress Disorder are derived from studies of effects of trauma on adults. Psychological trauma and life-threatening situations may produce different symptoms in children and adolescents than in adults. In recent years, research work has been done on the effects of trauma on children and adolescents. The American Academy of Child and Adolescent Psychiatry has written modified diagnostic criteria for Post Traumatic Stress Disorder in children and adolescents. However, short-term and long-term effects of acute and long-term psychological trauma due to terrorism on children need to be further investigated.

Early life experiences and post-traumatic stress disorders- It is now established that stresses caused by emotional trauma during early development, permanently affects the brain circuits critically involved in the regulation of stress and emotions. These biological scars then lead to altered behavioral and physiological responsiveness to the environment that ultimately increase the likelihood of adult psychopathology. It appears that the neurobiological effects of early life stress may represent priming for the development of PTSD in response to subsequent stresses. ⁵ Children who are exposed to early childhood traumatic experiences become vulnerable and are at greater risks for developing PTSD.⁶

            According to the Diagnostic Statistical Manual- DSM IV, the characteristic symptoms of acute stress disorder, such as anxiety, dissociation and other symptoms may develop within days to four weeks, after the exposure to extremely traumatic stressors such as threatened death or serious injury to self and others. The person’s response includes fear, horror, hopelessness, numbness, detachment, or absence of emotional responsiveness, depersonalization, dissociation, and amnesia (unable to recall an important aspect of trauma). The traumatic event is usually

re-experienced in recurrent images, thoughts, dreams, flashback episodes, or in a series of reliving the experiences. Symptoms may also include increased arousal (difficulty in sleeping, irritability, poor concentration, and restlessness), and avoidance of stimuli that arouse recollection of the trauma. If these symptoms persist beyond four weeks, the diagnosis of PTSD should be considered. The individual may feel guilty for surviving when others have not survived, and may feel responsible for the consequences of the trauma. Symptoms of depression, despair, and hopelessness may be persistent and severe enough to meet the criteria of major depression. These individuals are at high risk for development of post-traumatic stress disorder, impulsive and risk-taking behavior. ⁷

            Neurobiology of early life stresses and Post-traumatic Stress Disorder- Heim et al discussed in detail the neurobiology of early life experiences. Some regions of the brain may be particularly sensitive to adverse experiences which may lead to major and sometimes, irreversible abnormalities.  The stress response includes activation of the two major outflow systems, the sympathetic division of the autonomic nervous system and the hypothalamic-pituitary adrenal axis (HPA). ⁵

Sympathetic activation results in increased release of norepinephrine and changes in the blood flow to the medial temporal lobes and the orbito-frontal cortex during symptom provocation that is confirmed by PET imaging. ⁸ These brain areas are also involved in emotional processing.

          HPA Axis dysregulation. DeBellis described the biological and physiological changes in children with PTSD. Elevated levels of dopamine, norepinephrine and free cortisol in 24-hour urine specimens were found in traumatically exposed children. The urine catechilamine and free cortisol concentration were positively correlated with the duration of trauma and symptoms’ severity.^9-10 Significantly elevated salivary cortisol level is also found in a majority of children with PTSD, especially girls.¹¹ The increased secretion of glucocorticoids from adrenal cortex affects the metabolism, immune system, and the brain. These physiological changes are associated with behavioral changes such as fear, anxiety, and sleep disturbance, as well as fight and flight behavior. The pre-eminent neurotransmitter that coordinates these various stress response elements into one coping reaction is corticotopin-releasing factor (CRF), causing alteration of diurnal cycles of cortisol and altered peripheral catecholamine levels. Abnormalities on brain electrical activities, electroencephalogram (EEG) were also noted which are indicative of changes in cognitive processing of the emotional stimuli and structural brain development. ¹²

                One of the recognized functions of the hippocampus is converting short-term memories into long-term associations. The hippocampus is also involved in the control of the HPA axis, in explicit memory and in contextual aspects of fear conditioning.¹³ Specific changes in hippocampus are becoming hallmarks of PTSD.Traumatic stress releases glucocoticoid, which binds to hippocampal cells, and inhibit their normal memory functioning. Repeated application of stress hormones may cause cellular damage in the hippocampus. Postmortem inspection of the Hippocampus of patients with PTSD showed overall shrinkage caused by specific areas of atrophy. MRI of Patients with PTSD shows similar changes in Hippocampus. Medina pointed out that this data could also be interpreted to mean that patients who suffer from PTSD may have atrophied hippocampus and the traumatic experiences may result in the experiencing of PTSD symptoms. ¹⁴ Other MRI studies found attenuation in frontal lobe asymmetry, smaller total brain and cerebral volume. The apparent changes in brain architecture and metabolism may have functional implications as noted in the children with PTSD who have been found to perform more poorly than do the control subjects on measures of attention, abstract reasoning, and executive functioning.¹⁵

Diagnostic criteria for Post-Traumatic Stress Disorder-

                According to DSM IV PTSD in children has a different presentation and expression of symptoms than adults. A child’s response to stressful events may be expressed as disorganized or agitated behavior instead of intense fear, feelings of helplessness, or horror. Children re-experience or express the traumatic event or aspects of it through repetition play. Children’s dreams may be frightening but without recognizable content, or they may change into generalized nightmares of monsters, of rescuing others or of threats to self or others. These children tend to have more psychosomatic symptoms. ⁷ It needs to be mentioned that PSTD symptoms vary at different ages, and different developmental stages. These symptomatic changes are described in the American Academy of Child and Adolescent Psychiatry’s guidelines for assessing and treating PTSD. ¹⁸ According to their guidelines, young children may have recurrent recollection, post-traumatic play or play re-enactment, nightmares and episodes of objective features of a flashback or dissociation. Children may also show constriction of play, social withdrawal and a restricted range of affect and loss of acquired developmental skills (especially language and toilet training). As hyper-arousal symptoms in adults, children may express night terrors, difficulty in going to sleep, night awakening, decreased concentration, hyper vigilance, and exaggerated startle responses. Children may manifest different symptoms than they manifest initially, including aggression, separation anxiety, fear of darkness, and new fears not related to trauma. ^19-20

Stages of children's response to disaster: Most children respond to trauma of terror in two stages. The first stage immediately after the disaster includes reaction of fright, disbelief, denial, grief, and feelings of relief if loved ones have not been harmed ¹. A great deal of altruism is often displayed by children trying to help in the aftermath of such tragedies; this may help them develop resilience and also may be a marker of resilience ²¹. The second stage occurs a few days to several weeks after the disaster and is characterized by developmental regression in many children and manifestations of emotional distress such as anxiety. fear, sadness, and depressive symptoms, hostility, and aggressive behavior towards others, apathy, withdrawal, sleep disturbance, somatization, pessimistic thought of the future, and play demonstrating themes related to traumatic event ^1,22.

The response of younger children to disaster is dominated by mood, anxiety, and behavioral symptoms ²³. The younger children are not able to understand the intentions and logic of others and have great difficulty distinguishing a deliberate action from an unintentional incident. Although infants and toddlers may have no cognitive comprehension of a disaster, the loss of loved ones can lead to regression and detachment ¹. Such experience can manifest as increased crying and irritability and separation anxiety ²⁴. School-aged children often demonstrate the experience of trauma through play, expressing trauma related themes, and aggressive behavior. The older school children have greater capacity of social cognition and empathy. They tend to display more empathy for families who are affected by the crisisis.  They have greater capacity to understand why the tragedy occurred and focus more on the safety of the society as a whole. ^{3 25} 

Depression and suicide in children exposed to trauma-

                Based on data collected in the USA, it was found that PTSD occurs in 1-4% of the general population of children, exposed to violence, trauma, or abuse. ¹⁶ Foy et al reviewed 25 studies on PTSD children and found that 3 factors appeared to mediate the development of PTSD in children: the severity of trauma exposure, trauma related to parental distress, and temporal proximity to the traumatic events. ¹⁷

The traumatized children who require therapy for PTSD have been victims of chronic and multiple terror, rather than motor vehicle accidents, natural disasters, or isolated acts of terrorism. Symptoms of depression: despair and hopelessness may be persistent and result in prolonged depression in these children.

            The children and adolescents with traumatic grief are 4 times more likely to have suicidal thoughts. According to a study by Davidson, 19% of PTSD patients may ultimately commit suicide. The effect of violent death of significant others such as parents and siblings predicted a worse long-term outlook. These children experience more frequent re-experiencing of trauma, more disruption in their ability to attend school, and participate in the structured activities. Some children experience extreme anger, and when anger is mixed with suicidal thoughts, their acts become unpredictable ²⁶. In some cases, the adolescents with depression and anger may be prepared to die (by committing suicide) while killing others for the sake of the country. 

Intergenerational effects of terrorism-

Portney summarized some of the studies done on children of parents who suffered from prolonged trauma in Germany, due to Nazi atrocities. The parents were the survivors of the Holocaust who were exposed to prolonged traumatic stress. These parents constantly re-experienced the torture, and developed emotional numbing which did not help the child in developing a reasonable sense of safety, and predictability in the world. These parents have difficulty in modeling a healthy sense of identity, autonomy, and maintaining balanced perspective when life challenges arise. Instead they model catastrophic or inappropriately numb and dissociate responses. The parents’ higher level of anxiety did interfere with child development, and emotional maturity. Thus the prolonged psychological effect of trauma is passed on to the new generation ²⁷. The suicide bombings in Israel by Palestinian militants and the aggressive strikes on Palestinians by the Israeli military will producing the inter-generational anger and hatred in both Israelis and Palestinians, which may last for years.

Although children from my parts of the world have been exposed to acts of severe violence this article will specifically examine the studies and observations on short-term and long-term effects of exposure to terrorism on children of Bosnia, Israel, and Palestine.

Effects of terrorism on Bosnian children

Dr. Arshad Husain, in his book “Hope for the Children: Lessons from Bosnia,” elaborated on children’s experiences in Bosnia who faced death and destruction during the Serbian's attack on Bosnia during the mid-nineties. Dr. Husain found several unusual symptoms in the children who survived the massacres. Some children were afraid of light rather than darkness as light meant snipers could see and kill them. Some children experienced the symptoms of Post-Traumatic Stress disorder almost every night: children woke up in the middle of the night with terror and hiding in basements. Some children woke up with any noise that reminded them of shootings. Seventy percent of the Bosnian children had seen their parents or close relatives killed and these children had developed distressing symptoms of depression, low self-esteem, insomnia, and guilt. Some even expressed suicidal ideas saying: “I should have been dead before my mother.” 40% of children with PTSD showed all three types of symptoms re-experiencing, avoidance, and hyper arousal. Sometimes the children become confused and lose the ability to feel and express emotions such as “I feel so empty, sometimes I feel I am not alive. I am just here.” Some children give up their childhood and act like adults. A seven year old said, “We have to be strong and work hard for our country.” ²⁸

Effects of terrorism on Israeli children-

            Children in Israel have been exposed for years to suicide bombings. Dr. Kaplan of the Beth Sheva Mental Health Center in Israel has extensive experience of Post-Traumatic effects on Israeli children. Exposure to terror in Israel occurs as a victim or witness or as a relative, or as a friend of the victim.  Most mental health professionals in Israel are trained to identify post-traumatic symptoms in children more rapidly than in other countries and refer these children to one of the five post-traumatic centers where biomedical psychotherapeutic, familial and socio/occupational rehabilitation is available. ²⁹

Effects of terrorism on Palestinian children-

The author recently met a delegation of Palestinian mental health professionals visiting U.S.A. Their visit was arranged by the U.S State Deptartment to study the treatment strategies for children with PTSD. Most of the information I am presenting is based on information given to me by Palestinian mental health professionals. [add a reference to this personal communication] Some information is also gathered from the reports published in the press. [References needed] Very few research studies on the psychological effects of trauma on Palestinian children have been published.

Shafiq Masalha, a Palestinian psychologist, studied psychological consequences of prolonged trauma on 114 Palestinian children. He studied the dreams of children (9-10 year olds) to measure the psychological state of children. 79% of Palestinian children dreamt constantly about political violence, and 13% dreamt that they were killed, or sacrificing their own lives. These children were preoccupied with death in one form or another.  These dreams and preoccupations with the violence ultimately resulted in the expression of violent behavior. ³⁰ Mahmud Sehwail, a Palestinian psychiatrist stated that the Palestinian children do not suffer from post-traumatic stress disorder, but they suffer from continuing traumatic stress disorder. In the U.S. and other countries, a person usually gets one traumatic event, and later he lives in at least a protected environment. [insert reference to personal communication] In Palestine, children are not living in any protected environment. The situation is always unpredictable. They cannot even plan for the evening, or the next day. 30

The most significant experiences the Palestinian children have are of intense fear, helplessness, and horror. Some young children become agitated and do not want to be left alone. They cling to their mothers or surviving relatives. These children have difficulty in sleeping at night. They wake up in the middle of the night with nightmares, and frightening dreams, without recalling the contents. Even after the withdrawal of the Israeli army, they continued to live in a state of fear that at any moment, big Israeli tanks would return and they will be crushed. Mothers reassure the children, that they are safe but they also give a realistic explanation that if something happens to them, they will go to heaven and have eternal peace. Most of these parents themselves were exposed to terror, suffer from PTSD, and they have extreme difficulty in reassuring their children. Children are even afraid to go outside during the daytime or peep through windows due to the fear that the Israeli soldiers might kill them with a bullet. They are afraid that soldiers are waiting outside to kill them. The children’s lives revolve around their family, and their little home. When their houses and their little worlds are destroyed, they develop a sense of numbness, which is a characteristic symptom of PTSD. 

The children are developing unrestrained anger directed towards Israelis. Their feelings of helplessness create more anger and they are willing to fight against the Israeli soldiers with stones. The 10 or 12-year olds recall how their friends were throwing stones at soldiers and how they were shot dead. The children are angry, and even their parents cannot help them in reducing the fear anger and feeling of helplessness.

            Fourteen to sixteen year olds show more understanding. They verbalize the loss of their family, lands, their homes and the persistent humiliation under foreign occupation. These children do not believe the reassurance given by elders, that one day Palestine will become an independent state. They only see suffering, pain, and despair around them. They believe that they have nothing to look forward to except for misery, humiliation, and terror. These feelings further enforce their anger, and suicidal thoughts. They think of retaliation without worrying about the consequences. Dr. Iyad Sarraj, a Palestinian psychiatrist in Gaza City, has watched the suicide bombing with growing alarm. [insert reference to personal communication] Having grown up with the idea of suicide attacks, Palestinian children were equating death with “power” and are creating a new kind of culture and compensating for the powerlessness of their parents in the face of humiliation of Israeli occupation. Some suicide bombers had no connection with the militant Islamic groups like Hamas and Islamic Jihad, and most of them did not go through the months of preparation that has been repeatedly mentioned in Western media. These young adults die with the hope that giving their lives will give lives to others. The principle behind suicide bombing is that it is better to die in dignity rather than to live in humiliation and shame. ³¹

        Conclusion     Individuals who are exposed to serious psychological traumas and develop PTSD may have multiple co-morbid illnesses, multiple medical and psychiatric problems including hypertension, bronchial asthma and peptic ulcer. Substance abuse, anxiety and depression are also common occurrences and some times, the symptoms of co morbidity mask the diagnosis of PTSD. Many of these children develop depression. Incidence of suicide is also high in PTSD patients. In some cases, the depression changes to anger and a small number of these adolescents are prepared to die while killing for the sake of their country. They die with a hope that giving their lives will give lives to others. To prevent depression, despair, anger and revenge, therapeutic intervention is necessary. With limited resources and insurmountable problems, this is a difficult, if not an impossible task.

            The traumatized children should be screened for anxiety, depression, and behavioral problems. Parents should be also counseled regarding the range of normal, emotional, and behavioral reactions of children to terror and the symptoms children manifest which they should be concerned about. Individuals and family counseling is strongly recommended to prevent severe consequences of psychological trauma.

Therapeutic interventions like Critical Incident Stress De-briefings, Prolonged Exposure Therapy (PET), emotional support, and psycho education proves to be beneficial in treating children exposed to trauma, and these techniques also help in preventing the subsequent development of PTSD. Many medications like SSRI’s, Tricycylic antidepressants, and Anti-anxiety medications have been used for treatment of PTSD. American Academy of Child and Adolescent Psychiatry practice guidelines defer to the psychiatrist’s judgment to determine the best pharmacological approach.  ^32-6

            The U.S Dept. of Health and Human Services awarded 10 million dollars in grants for treatment of children and adolescents who have experienced traumatic events after Sept.11, 2001. Fortunately, the Israeli children exposed to traumatic stress have institutions, and professional staff to help and treat them. The goal is to stabilize and prepare them to live a normal life.

The Palestinian children with traumatic experiences live in the same environment of misery and suffering but with severely limited therapeutic intervention. Without some kind of assistance to the Palestinian children and an end to occupation, the suffering of the Palestinian children, the cycle of violence is likely to continue.

Dr. M. Basheer Ahmed is a former professor of Psychiatry at Southwestern Medical School, Dallas, Texas, and currently in private practice of Psychiatry in Fort Worth, Texas. He can be reached at: This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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