"Mom, do we hear the siren when we die?"

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or Israeli youths, enlisting in the IDF is a rite of passage, marking the end of adolescence. But for those Israelis who grew up in the shadow of the rockets fired from the Gaza Strip, the so-called Qassam Generation, years of military tension have left deep scars from infancy, through childhood and adolescence, to adulthood.

Ron Calderon from Kibbutz Sufa has been suffering from PTSD since a Qassam rocket exploded near his kindergarten in April 2008. He was four years old at the time.

"Ron was in the playground with all the other children," says his mother, Sharon Calderon. "He didn’t see the rocket actual fall, but the whole experience has left him where his is now. He only started talking about his memories two years ago, so we don't really know what happened."

At first, Ron was diagnosed with anxiety. Later, he was found to be suffering from PTSD and was recognized by the National Insurance Institute as a victim of terrorist acts on the grounds of mental health. "Ron has had panic and anger attacks, cursing, and shouting," according to Sharon. "He withdraws into himself, cries, and shakes."

Since 2018, whenever there is an uptick in rocket attacks, Ron’s situation worsens. He suffers from shortness of breath and has fainted on several occasions. "These frequent flare־ups set us back years. It is as if all the therapy and support have gone down the drain, and in our case, we are talking about 12 years. It’s very difficult to treat anything when anxiety lurks in the background."

Ron is now a 16־year־old high school student who needs an aide with him at all times. Sharon says that she often receives a phone call from school, drops what she is doing, and drives to him. She does not dare venture more than a few miles from home.

Sharon Calderon: "For the past 12 years, I have put my life on hold. Once we understood the severity of PTSD, my husband and I decided that he would be the main breadwinner and I would do whatever work I could that would enable me to be there for Ron."

How did PTSD change your life?

"For the past 12 years, I have put my life on hold. Once we understood the severity of PTSD, my husband and I decided that he would be the main breadwinner and I would do whatever work I could that would enable me to be there for Ron. I worked, but I couldn’t hold down a job for more than two years. It’s a problem when you sometimes need to leave work once a day for two weeks. I couldn’t go and study anything, I couldn’t work far from home, and I didn’t pursue a career. I have a lot of skills, but I don’t have any certificates to prove it. This year, I have begun to give lectures on the subject and to bring it out into the open."

One in the three children (at least)

Tragically, Israel is fertile ground for conducting research into post־trauma. it is an exceptionally good laboratory. Talia Levanon, the director of the Israel Trauma Coalition estimates that 11-13 percent of Israelis suffer from post־trauma as a result of the security situation - and residents of the Gaza border area are top of the list. According to the Health Ministry, 10 percent of the population suffers from security־related trauma and that "these figures are higher - up to 20 percent - in the Gaza border area, because of the chronic nature of the fighting."

What, then, are the figures for PTSD among children in the Gaza border area? According to a 2010 study, more than 13 percent of the 1,000 children who participated were diagnosed will full post־trauma and 30 percent from partial post־trauma, while another study found that 40 percent of the children in the area suffer from anxiety and PTSD symptoms.

One of the clear conclusions of these studies was the crucial impact of how mothers cope with the security situation. They found that one third of mothers in the Gaza border area suffer from PTSD symptoms and almost one third suffer from depression - a rate which is four times higher than among the general population. Some of the mothers were found to suffer from both conditions, with a total of 44 percent of mothers suffering from some kind of mental distress.

One of the academics involved in these studies, Prof. Ruth Pat־Horenczyk, writes that, "The child is more influenced by their mother’s mental state than by the missiles. I state this with full confidence. Young children are more influenced by how their mother copes at home than by the objective situation; the more dangerous missile is in the home."

Moran־Hila Madmoni: "People don’t understand that we are constantly on high alert. My younger son, Yedidya (aged 5), is on edge and whenever he hears any kind of noise, he asks whether this is a missile siren. At night, both children sleep in our bed because they are so frightened."

Yizhar Sha’ar, director of Eshkol Region Educational Psychological Service, says that, in the past six years, his department has treated a quarter of the children and adolescents who live in the region, which translates into 1,000 students a year. According to Sha’ar, the challenges facing children living in the Gaza border area, compared to elsewhere in Israel, are exacerbated by the security situation. For example, someone with an attention disorder cannot be treated in the optimal manner because the relevant medication might increase anxiety.

"They are sometimes given lower doses of the medication and then the effect is reduced," he explains. "Others cannot focus, be attentive, or be helped with treatment that might help their functioning. This includes teens who cannot achieve the scores they deserve in their matriculation tests."

Sha’ar says that the regional council asked the Education Ministry to be more lenient in these exams and grade on a more accommodating curve. The government refused. "How can the students possibly learn when they are always in stressful situations, when they don’t sleep at night? It is impossible to reach the same level of achievement as the rest of the population," he says

The following example illustrates this point. In February, the Ynet news website published matriculation scores per city. In the most advances math and English tests, Sderot came bottom of the table. The average math score in Sderot was 62.5, compared with the national average of 82.3. In the English test, the score was 77 compared to the national average of 88.3. Nonetheless, the percentage of graduating students in the city stood at 86 percent.

Angry and depressed

Along with the figures that show the rates of PTSD among residents of the south, another fundamental issue needs to be addressed: the inner turmoil experienced by residents of the Gaza border area does not always fit the dry criteria defined in the academic literature on PTSD. The situation is, therefore, even more complex - so too are the ramifications.

"The term post־trauma is problematic when referring to the people in the south because the current situation is not ‘post’ - it is a constant, ongoing situation and the threat is ever present," says Talia Levanon.

Sha’ar agrees. "The conceptualization in the Gaza border area is completely different; we are talking about an ongoing trauma. Post־trauma describes a situation in which an event occurred and, as a result, the person develops trauma with intrusive thoughts, avoidance, flashbacks, and other symptoms. Here in the Gaza border area, the situation continues to exist and the fear is that it will continue to exist. You cannot tell a person ‘Something happened, we will treat you, and you are now in a safe place.’ The therapy is different from most of the methods used to treat people in war zones and the symptoms are widespread and include several categories."

What are the implications of ongoing trauma?

"Studies show that the rate of depression among people living in the Gaza border area is three times higher than the general population, likewise the rate of aggression," Sha'ar explains. "There are PTSD symptoms such as avoidance or hypervigilance as well as somatization (a tendency to experience physical distress as a result of psychological distress). The body can no longer bear the ongoing pain and reacts by manifesting many physical symptoms. The patient complains of headaches, abdominal pain, and nausea. Diseases develop that have no medical reason. It has also been demonstrated that there is a tendency to develop substance addictions and to have difficulties in interpersonal relationships and problems sleeping.

Hadas Tzalach: "They don’t want to go to the bathroom by themselves because they are frightened. They won’t agree to go for a walk or to play in the garden because they heard that a siren sounded in Sderot and are frightened that it will also sound here. People cannot understand the ramifications."

"Among children we see anxiety and regressive behavior. For example, those who were toilet trained return to bed wetting, those who were independent now want to sleep with their parents at night or stop doing things that they did previously. These are human expressions of how the mind and soul manage to survive in an impossible situation," he adds.

"We know that there is an increase in cases of obesity and diabetes among children living in the Gaza border area," according to Levanon. "No study has been done on this, but the working assumption is that it is connected to the security situation."

Over the past few months, residents of the Gaza border area have been trying to drum up solidarity from people all over Israel. For example, 'Voice of Mothers' is reaching out to Israeli women and their sense of maternal solidarity. They want mothers everywhere to be aware of the conditions under which they are raising their children.

A search of social media networks reveals a plethora of mothers telling their stories of life in the region. One mother wrote: "To be a mother in the Gaza border area is to be on alert at all times. It is to sleep fully dressed as if you were on call in the army. It is constantly to live with the conflict of whether to stay or to flee. It is to go crazy with worry until your heart explodes. It is to be at home and not feel safe."

Another mother wrote: "Yesterday he talked non־stop for one and a half hours. When I told him that he was getting on my nerves, he said, ‘I am talking to keep the thoughts away. You don’t have to listen, just nod every now and again."

Another mother described all the small annoyances she has to take into account: they can't close the door to the bathroom or shower because opening the door wastes one of the seven seconds they have to run to the safe room. One day, she persuaded her daughter to wash her hair: "‘But Mom, what happens if there is a missile attack and I have shampoo in my eyes?" I convinced her that there wouldn’t be an attack, but the moment the foam began trickling down her hair, there was a sharp whistle and the siren sounded. ‘Mom, you lied to me,’ she said."

"My son wanted a place to scream"

Moran־Hila Madmoni lives in Sderot. Her 9־year־old son, Yisrael Meir, has been stuttering ever since 2014's Operation Protective Edge. "Stuttering is not considered post־trauma, but it is an ongoing trauma," she says.

"As far as I am concerned, we are fully־fledged victims of terror just like anyone else. A balloon with explosives attached to it is just like a missile. It kills. Children are traumatized by them and mental־health victims are no less victims than those who are physically injured. People don’t understand that we are constantly on high alert. My younger son, Yedidya (aged 5), is on edge and whenever he hears any kind of noise, he asks whether this is a missile siren. At night, both children sleep in our bed because they are so frightened."

Talia Levanon, the director of the Israel Trauma Coalition estimates that 11-13 percent of Israelis suffer from post־trauma as a result of the security situation - and residents of the Gaza border area are top of the list. According to the Health Ministry, 10 percent of the population suffers from security־related trauma and that "these figures are higher - up to 20 percent - in the Gaza border area".

Madmoni says that her older son has been treated at the city's mental health center since he was three, adding that she and her husband also go there for guidance. "Dealing with him is tough. I’ll give you just one example: One Saturday evening we were driving home to Sderot after spending Shabbat with my parents just outside Jerusalem. The children knew that the missile siren had sounded in Sderot during Shabbat. As we were driving, my older son asked whether we could make a stopover at a forest because he wanted to scream. We took him to a spot in the forest, he was a bit frightened to get out of the car, but I told him that he was allowed to and that this was a way of relieving some of the tension. I’ve also learned to dance with my fears. He then returned to the car, and drover home. I could hear that his breathing was heavy, and then he asked us: ‘Do we hear the siren when we die?’"

How did you react?

"We always tell the truth, and they are children who talk a lot about death and fears. But we really didn’t know what to do with this question. He is a very clever boy who understands everything. He once asked me whether he has to enlist in the army. I replied that it is a privilege to serve in the IDF. He replied, ‘I’m already a soldier but without a uniform. I am defending with my own body'."

How does it feel when the siren sounds and your children are not with you?

"Try to imagine the most painful contraction you ever had when giving birth. That is exactly what happens when the children are not next to us. Words cannot describe the feeling; you have to experience it. If we were to have a medical examination that very second, I think they would see how the body reacts physically."

Dalya Yosef, director of the helpline operated by the Israel Trauma and Resiliency Center (NATAL) says that most of the cases she gets involve the entire family. "Most of the calls to our helpline are from parents living in the south whose children suffer from anxiety," she says, in an interview which took place before the COVID-19 pandemic.

"There is a wide age range of ages - from kindergarteners to adolescents who are about to enlist to the IDF. We are seeing a very significant increase in calls during both periods of calm and, of course, times of emergency. We live in a country where the circles of those injured has widened and the home front is becoming the frontline."

NATAL’s figures highlight the suffering of families in the Gaza border area: of 4,350 new calls to the helpline in 2019, 72 percent came from residents of the south, and 35 percent of these were calls for help for children and adolescents reporting PTSD symptoms. In the same year, the number of children who were treated at NATAL’s therapeutic unit increased by 40 percent, most of whom lived in the south.

Childhood's end, innocence over

Hadas Tzalach is married and lives in Ashkelon with her 8־year־old daughter and twin 6־year־old boys. When her daughter was working on a school project on feelings and emotions, "She cut out the letters peh, het, and dalet [which form the word 'fear' in Hebrew], stuck them on a piece of black paper, and brought it home. In infancy, there isn’t any awareness; then, slowly but surely, when my daughter understood the meaning, the anxiety began. We would go to the emergency room when she complained of chest pains and said she couldn't breathe. At first, we did not realize that these were panic attacks."

What happens on days when the siren sounds?

"If there is a siren at night, she doesn’t go to school the next day because she is frightened. When there is a chance that the siren may sound, she prefers to sleep in the safe room because she is frightened. If I take her out for pizza in Tel Aviv and she hears the sound of a motorbike, she jumps from fear. This would not happen to a girl who lives in Tel Aviv."

How does it affect the twins?

"They don’t want to go to the bathroom by themselves because they are frightened. They won’t agree to go for a walk or to play in the garden because they heard that a siren sounded in Sderot and are frightened that it will also sound here. People cannot understand the ramifications. Sometimes we hear the siren and then they say it was a false alarm. What difference does that make? The children experienced the same hysteria."

Tzalach is a balloon artist. For years she has taught children what fun it is to twist balloons into interesting shapes and not to be afraid if the balloon bursts. Things have changed - in addition to rockets, terrorists in Gaza are floating balloons with explosive devices attached to them over the border - and now she repeatedly warns them not to go near balloons when they are out.

"In my house, they all grew up with balloons. How has such a happy item become such a dangerous object that you mustn’t go near? They took all the good, the joy and innocence of the children, and simply destroyed it."

I asked Tali Levanon of the Israel Trauma Coalition what kind of adults will the children living in the Gaza border area become as a result of growing up in these circumstances.

"We have to be very cautious because, while we are talking about trauma, we also have to remember that Israel is characterized by a high degree of resilience," she says. "Growing up in this country, Israelis internalize that there is hardship as a result of the security situation. This becomes part of their DNA and they develop coping mechanisms on both an individual and a societal level. However, I believe that some of these children will grow up to be adults with one hand tied behind their back. In other words, they will have difficulty in some areas concerning quality of life. This is not only measured in terms of trauma, but also in the ability to live life to its fullest. This situation affects a person’s ability to forge interpersonal relationships, to love oneself, and to cope with day־to־day challenges."

Levanon describes herself as an optimist who "wants to build resilience and doesn’t want to frighten the public." She concludes by saying that one of two things could happen: "The first is that resilience will be created, and the second is that trauma will be created. Unfortunately, both could happen; in other words, a person has a high degree of resilience and is, nevertheless, still traumatized."

Without hope, coping is impossible

Emotional resilience refers to the ability to return to full, and even improved, functioning after a difficult event, situation, or period. Therapists and educators report that over the past two years, since the escalation in March 2018, they have, for the first time, been seeing cracks in the famous resilience of the Gaza border area residents. The clashes on the border between Israel and Gaza terrorists included persistent terror attacks, Qassam rockets, tunnels, explosive kites and balloons, and sirens sounding at all times of day and night. The number of anxiety victims has shot up accordingly. In 2019, the resilience centers in the area treated 4,348 anxiety victims - compared with 2,385 in 2017.

A sign hangs in the group therapy room in the Eshkol resilience center reads: "Hope is the only thing that can beat fear."

Merav Vidal is a social worker who heads the center. "This is very important. If there is no hope, it is impossible to cope with fear. The last two years have not just been more of the same that we have gotten used to; the magnitude is beyond the limits of human endurance. The people here are strong and have powerful resources: they have values and believe in being active and have received many tools over the years that have bolstered these resources. If they are feeling cracks in their resilience, we really should be worried."

"We are now beginning to see more chronic trauma, even though the numbers are still low," Vidal adds. "Prior to 2018, despite the fact that there had been long־term exposure to terror with Operation Cast Lead, Operation Pillar of Defense, and Operation Protective Edge, those who were in therapy were being helped and their symptoms didn’t deteriorate. The number of people with chronic trauma was negligible. Now, we have more and more cases of people who need psychiatric intervention and medication and are being diagnosed as PTSD sufferers."

How is this expressed in figures?

"Out of the 900 people we saw in 2019, 37 were given a psychiatric diagnosis of PTSD. In the past, such people would have been given this diagnosis after they experienced an event that included physical injury or loss. Now, however, they are diagnosed because of long־term exposure to events here. After we succeeded in maintaining a high level of resilience for years, in 2018 we began to realize that we are dealing with something else, not only with regard to the number of people contacting us for help but also in the nature of the treatment. Something different is going on now, we are seeing fatigue, anxiety about what the future holds, expectations, and great confusion. People know how to cope in challenging emergency situations and draw on their resources and, when things calm down, return to their normal selves. In the past two years, we have been living in a non־stop, intensive emergency situation, but no definition has been given to the situation, which is very confusing and drains people of their energy."