Amjad Joma
Olivier Arvisais- 1A’Sharqiyah University, Ibra, Oman
- 2Universite du Quebec a Montreal, Montreal, QC, Canada
Against the backdrop of ongoing conflict in the Occupied Palestinian Territories, this study investigates the complex relationship between stress, well-being, and learning in children. Utilizing a multi-case approach, researchers meticulously evaluated six children from one of the refugee camps in the West Bank. They measured variables such as exposure to potentially traumatic events, perceived stress levels, physiological stress responses, resilience, and cognitive performance to assess their findings. Despite experiencing high levels of political violence, the participants demonstrated a predominant trend toward strong resilience and overall well-being. However, significant differences emerged between self-reported stress scores and objective physiological measurements, highlighting the need for a comprehensive approach in understanding children’s experiences of stress. An evaluation of cognitive abilities demonstrated significant cognitive inhibition and difficulties with working memory and cognitive flexibility. This study illuminates the multifaceted nature of children’s responses to stress in regions affected by conflict, emphasizing the pressing necessity for customized pedagogical approaches and extensive research to improve understanding and intervention strategies.
Introduction
With millions of children worldwide affected by past and ongoing wars and conflicts, there is an urgent and growing need for research to inform efforts aimed at understanding, preventing, and mitigating the potential consequences of this violence for children, families, and communities, for both present and future generations. Political violence and armed conflicts put people of all ages at risk, but developing children are especially vulnerable to the long-lasting negative psychosocial consequences of these situations (Nemeth and Glozman, 2020; Joma et al., 2022). Over the past 20 years, Palestinians have endured four wars that have resulted in many casualties and widespread psychological trauma, particularly among children (El-Khodary et al., 2020; Shaheen et al., 2025).
Since 2018, thousands of Palestinians have participated in weekly protests that have had significant repercussions on the well-being of young people, resulting in considerable impacts on children’s education (UNRWA, 2019; Migdad et al., 2021). As a result, there have been calls for improved psychosocial support and resources from educators and parents, both within and outside of the school environment, to better assist children in dealing with the aftermath of this political violence. Abo Hamza et al. (2019) estimated that 51% of children in the Gaza Strip experience Post-Traumatic Stress Disorder (PTSD). Additionally, a significant proportion of these children suffer from chronic stress, anxiety and depression, emotional regulation disorders, and sleep disorders. This situation significantly impedes their ability to access quality education and engage in uninterrupted learning without disturbance due to the crisis. Moreover, the Global Monitoring Report on Education for All prioritized education in conflict contexts and stressed the significance of psychosocial interventions in counteracting the destructive effects of conflicts, such as depression, trauma, shame, and dropouts, which can significantly impede learning (UNESCO, 2011). As per the UNRWA report in 2019, teachers frequently express apprehensions regarding the impact of such circumstances on their students’ emotional and psychosocial wellness. They view these factors as influential in low academic achievement and behavioral problems in the classroom, especially for male students. These obstacles, combined with political instability and socioeconomic barriers, result in a highly complex learning environment for the children.
This case study was conducted in a refugee camp, located in the Occupied Palestinian Territories (OPT). This camp holds a strategic geographical position, near the main checkpoint between Ramallah and Jerusalem. Violent confrontations between Israeli forces and Palestinians occur frequently, resulting in injuries and deaths among residents. In addition to political and military conflicts, the camp also endures significant socio-economic challenges. With a high unemployment rate, considerable overcrowding, and frequent incursions by Israeli forces, the camp’s social fabric is severely disrupted. Moreover, deteriorating economic conditions have led to a surge in violence and illicit behaviors in recent years (UNRWA, 2019).
Numerous studies suggest a dynamic link between education and psychosocial support (Afana et al., 2020; Tol et al., 2011). Research indicates that offering children structured, relevant, and creative activities in educational settings can contribute to enhancing their emotional and behavioral well-being (Ager et al., 2011; Berger and Gelkopf, 2009; Kostelny and Wessells, 2008). Moreover, although additional research is required, certain psychosocial support programs also appear to have a positive impact on classroom results (Betancourt et al., 2014; Layne et al., 2008; Woodside et al., 1999). Nevertheless, the mechanisms that promote stronger resilience capacity in children in emergency settings remain largely unknown, and future studies are needed to gain a more detailed understanding of the efficacy of various psychosocial programs (Burde et al., 2017).
Scientific literature emphasizes that research on children exposed to political violence and armed conflicts is crucial to (1) promote healthy child development; (2) enhance the resilience and human capital of affected communities; and (3) foster positive long-term outcomes, particularly in preventing the recurrence of violent conflicts (Cavazzoni et al., 2020; Cahill and Foa, 2007). To inform interventions and policies aimed at improving the lives of vulnerable children, it is essential to focus research programs not only on documenting outcomes in children exposed to political violence and armed conflicts but also on identifying the pathways and processes through which exposure leads to specific problems over time (Cairns and Dawes, 1996; Cicchetti and Cohen, 2006; Sroufe, 2013). Unfortunately, process-focused research studying children, political violence, and armed conflicts remain scant to date. Therefore, our study aims to fill that gap related to lack of sufficient knowledge about how stress exposure affects children’s executive functions and academic trajectories and which protective factors may mitigate these effects in conflict-affected settings.
This study is based on recent advances in two fields: (1) developmental psychopathology in children residing in areas affected by political violence and (2) education in situations of armed conflict. It contributes to a deeper comprehension of the relationship between stressors intensity, chronic stress, well-being, psychological resilience, executive function skills, and learning among primary school students in the West Bank. The study aims to develop a better understanding of the interactions between variables in the vulnerability-stress model (REF). Additionally, we aim to test the present methodology, which is commonly used in stable and developed contexts, with vulnerable populations affected by armed conflict to outline all logistical, methodological, and ethical challenges involved.
Conceptual framework
Recent studies have shown that children’s cognitive development is seriously compromised by exposure to political violence (Al-Krenawi et al., 2007; Thabet et al., 2018; Joma and Lekan, 2024; Arvisais et al., 2026). Some research suggests a correlation between disorders in which emotions are the primary feature and the development of specific executive functions, particularly inhibitory control (Nemeth and Glozman, 2020). These executive functions play a significant role in many school-related tasks (Borst and Houdé, 2014). Concurrently, literature indicates that populations residing in areas with armed conflict and political violence need to proactively secure their own safety while preserving their well-being and development (Williamson and Robinson, 2006). In this regard, although external support may be helpful at various levels, children can still demonstrate resilience when dealing with trauma (Nemeth and Glozman, 2020; Liebenberg et al., 2012). Resilience is defined as the capacity of individuals to acquire the psychological, social, cultural, and physical resources necessary for their well-being. Additionally, it includes their individual and collective ability to ensure that these resources are provided and experienced in a culturally appropriate manner during times of adversity (American Psychological Association, 2008).
Concurrently, recent research (Blanchette et al., 2019; Caparos et al., 2018) emphasizes the significance of evaluating the cognitive response in addition to the emotional response to trauma. Longitudinal studies of young adults substantiate that cognitive capabilities moderate the effects of traumatic event exposure (Petrides and Milner, 1982; Parslow and Jorm, 2007). Based on these studies, we aim to investigate the innovative prospect that education, which significantly boosts the growth of working memory abilities and other executive functions, might mitigate the adverse influence of exposure to traumatic experiences in children, consequently fostering resilience (Breslau and Schultz, 2013; Macklin et al., 1998). In this context, it is important to comprehend the factors that enable children to develop resilience capacity and attain the resources for their well-being, given that resilience significantly impacts one’s ability to lead a healthy life in the midst of a crisis (Daigneault et al., 2013; Ungar, 2008; Rolf et al., 1990), which seeks to explain the processes underlying the development of resilience in children. Therefore, the main theoretical framework adopted in this study is that of developmental psychopathology (Cicchetti and Cohen, 2006; Cummings et al., 2000). This perspective, called transactional, arises from interactions between an individual’s characteristics and those of the environment, which both develop together over time (Sameroff, 2010; Sameroff and Mackenzie, 2003).
More specifically, to better elucidate the role of stress in the development of psychopathology, we have chosen the model proposed by Grant et al. (2003). This model is based on five assumptions: (1) stress contributes to the onset of mental health conditions (Grant et al., 2006; Joma and Lekan, 2024); (2) various individual characteristics (e.g., age, gender, maturity, etc.) are important factors in the manifestation of such conditions. The relationship between stress and mental health issues is explained by biological, psychological, and social processes (McEwen, 1998). Individual characteristics interact with experienced stress to establish a unique developmental trajectory for each person (Sameroff, 2010). The interactions between risk and protective factors create an evolving reciprocity (Sameroff et al., 2000). It is essential to consider how individual characteristics may attenuate or amplify the relationship between stress and mental health issues. This postulate asserts that each variable in the model has an impact on the others. Additionally, the significance of certain variables within the model may differ based on unique stress factors affecting each individual.
Finally, the model’s reciprocity enables prediction of both the development of problems and exacerbation of symptoms along the mental health continuum (Grant et al., 2006). Within the context of this study, we will utilize a sub-model of the developmental psychopathology model, namely, the vulnerability-stress model that has been adapted to the school context and integrates executive functions and learning dimensions, as illustrated in the accompanying figure (Massé et al., 2020a,b; Ehlers and Clark, 2000). It interacts with variables that represent biopsychosocial vulnerabilities, the stress variable, protective variables such as well-being and resilience, and skills related to executive functions and learning (Sanders et al., 2015).
Methodology
As part of a multiple case holistic study (Yin, 2009), we examined six cases that we consider representative of a typical situation among primary school students in refugee camps around the city of Ramallah in the occupied Palestinian territories. This pilot study strives to establish a methodology that will ease the production of knowledge valuable for conducting statistically generalizable studies in the future (Cadario et al., 2020; Yin, 2003).
Participants and sampling procedures
The study was conducted with a group of participants who demonstrated certain distinct characteristics. The sample comprised six boys aged 9 to 11 years old enrolled in grades 4 through 6 at the camp school, an institution managed by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA). The socioeconomic background of these children varied from low to medium, revealing the educational and life experiences of children within this demographic group.
A purposive convenience sampling strategy was adopted for this pilot study to identify children with recent exposure to potentially traumatic events, in line with the study’s exploratory objectives. Inclusion criteria were: (1) age between 9 and 11 years, (2) enrollment in the camp school, (3) exposure to at least one potentially traumatic event in the previous 3 months, and (4) ability to provide assent and participate in study procedures. Exclusion criteria included diagnosed neurological disorders, severe psychiatric conditions requiring immediate clinical intervention, or medication known to affect cortisol activity. During the recruitment period, six families meeting these criteria were identified and invited to participate. All eligible children agreed to participate and completed the full study protocol, and no participants were excluded or discarded after enrollment. The final sample therefore represents the entire accessible and eligible population available for this pilot study, rather than a subset selected from a larger pool.
Seven variables are considered and evaluated through data collection tools, chosen for their administration time, cultural references, and language compatibility. These tools, originally developed and used in western contexts, were revised by Palestinian researchers in order to adapt them to the Palestinian context.
Ethical procedures
Consistent with ethical guidelines for research involving vulnerable populations, enhanced ethical safeguards were implemented at all stages of the study. Written informed consent was obtained in Arabic from parents or legal guardians, and assent was obtained from all participating children. Parents were provided with a detailed explanation of the study objectives, procedures, potential risks, and benefits, as well as their right to withdraw their child from the study at any time without penalty or adverse consequences. To minimize potential distress, a distress protocol was established prior to data collection. Researchers were trained to monitor signs of emotional discomfort during study procedures and to suspend or terminate participation if distress was observed or reported. When appropriate, participants and their families were offered referral to a local non-governmental organization (NGO) providing psychological and psychosocial support services, with which the research team collaborated. Participant confidentiality was ensured through the use of anonymized identification codes and secure digital data storage on encrypted, password-protected servers. Access to all study documents and datasets was restricted to the research team. Schools and community organizations were not granted access to any information that could directly or indirectly identify individual participants.
Training and oversight of cortisol collection
Parents received structured training on saliva collection procedures, including timing, hygiene, sample handling, and storage requirements. Training sessions were conducted in person at the community center using demonstrations, printed illustrated guides in Arabic, and practice trials. Daily adherence was monitored using a parent-completed logbook documenting extraction times, wake times, sleep quality, unusual events, and child health status.
Follow-up phone calls were conducted each morning to verify adherence, clarify instructions, and ensure timely sample refrigeration. Parents were instructed to place samples immediately in a cold pack and deliver them to the designated collection point within 24 h, where field researchers inspected, labeled, and transported them in dry-ice containers to the laboratory. Samples with timing deviations or insufficient volume were flagged, and when necessary, recollected.
Control and monitoring of confounding variables
Given the sensitivity of cortisol and cognitive performance to contextual factors, potential confounders were tracked systematically. Sleep patterns, nutrition, illness, medication use, and major family stressors were documented daily through the logbook and follow-up calls. Information about exposure to acute political events (e.g., clashes, incursions, tear gas) was collected through parent interviews and triangulated with community reports. Environmental noise and overcrowding in homes, known to affect diurnal cortisol, were documented through short structured interviews. Although confounders could not be fully controlled in this real-world context, close monitoring allowed us to account for deviations during interpretation.
Measurement tools overview
Diurnal cortisol secretion
To evaluate the stress levels of the participants, we measured their diurnal cortisol secretion. To establish baseline measurements for each participant, we collected 15 saliva samples over 3 days, taken at five distinct times each day: (1) upon awakening, (2) 30 min after awakening, (3) 2:00 p.m., (4) 4:00 p.m., and (5) at bedtime. For each sample, participants expectorated 2 mL of saliva into a tube. To collect saliva samples, tubes (Sarstedt©, reference number 62.558.201) were provided to the participants along with detailed instructions. All necessary materials were provided to the participants, which were color-coded and accompanied by instructions in Arabic. All samples were collected at the participants’ homes or through the community center and transported in an icebox with dry ice.
Salivary cortisol concentrations were analyzed at a private laboratory in Ramallah using the procedure developed by the Centre for Studies on Human Stress (Lupien, 2013). Salivary cortisol samples were analyzed at the private laboratory in Ramallah (Cisjordanie). Frozen samples were brought to room temperature and centrifuged at 5000 × g for 10 min. at 2–8 °C (Roche Diagnostics, 2015). Electrochemiluminescence immunoassays were used with the human Elecsys Cortisol II kit with the modular analytics system E170 Cobas e 411 (Elecsys® Catalog No: 06687733190, sensitivity < 0.054 μg/dL, coefficient of variation is < 10%). The cortisol detection range is 6.25–400 ng/mL. All assays were duplicated and averaged (Elabscience, n.d.). Additionally, the Perceived Stress Scale for Children (PSS-C) developed by White (2014) was used as a supplementary measure.
Perceived stress
Subjective perceptions of stress were measured using the 13-item Perceived Stress Scale for Children (PSS-C; White, 2014), scored on a 1–4 Likert scale. Total scores in this study ranged from 13 to 52, with higher scores indicating greater perceived stress. An Arabic adaptation of the PSS-C was developed by the research team specifically for this pilot study through an iterative translation and cultural adaptation process. Internal consistency was examined for the adapted Arabic version of the PSS-C; however, given the pilot nature of the study and the very small sample size (N = 6), the resulting Cronbach’s α estimate was unstable and not interpretable. Accordingly, the scale was used as a complementary subjective indicator to support convergent or non-convergent interpretation alongside physiological stress measures, rather than for psychometric validation. The same applies to the following scales (well-being, trauma exposure, and resilience), internal consistency estimates were not considered interpretable.
Well-being and exposure to traumatic events
Psychosocial well-being was measured using a 40-item Arabic questionnaire previously validated in Gaza and applied in both Gaza and the West Bank without modification (Joma et al., 2021). Items cover physical, social, academic, and psychological dimensions of well-being and are rated on a five-point Likert scale. This stability across contexts ensures comparability between participants from different regions. The validity of the study tool was examined by content validity and internal consistency validity. A group of psychosocial support and mental health experts evaluated the content validity. Accordingly, the items were modified.
A pilot study was performed for 30 children from the target population excluded from the sample size to confirm the validity and the internal consistency and reliability of the psychosocial well-being questionnaire that was adapted and adopted in the current study by using the correlation coefficients of Cronbach’s alpha. The pilot study was conducted after permission was obtained, information about the research and its objectives was provided to the participants, and a consent form was signed. As a result of the pilot study, the questionnaire was clear, easy to understand, and gave a satisfactory interpretation of the data and minimum participant errors. Cronbach’s alpha scores were 0.84 for the physical dimension, 0.74 for the social dimension, 0.79 for the academic dimension, and 0.85 for the psychological dimension. Cronbach’s alpha was 0.80 in the study.
Exposure to potentially traumatic events during the previous 3 months was assessed using an events checklist. This list was adapted collaboratively by colleagues from Gaza and the West Bank to ensure contextual relevance and accurate reflection of the types of violence and adversity typically experienced by children in both settings. The tool documents both frequency and type of exposure.
Resilience
Resilience was assessed using the official Arabic translation of the Child and Youth Resilience Measure (CYRM-17; Ungar, 2008). The CYRM-17 is a widely used measure of socio-ecological resilience across three domains: personal (skills, peer support, social competence), relational (caregiving, physical and emotional support), and contextual (spiritual, cultural, and educational resources). All items are rated on a five-point Likert scale. The CYRM-17 has demonstrated good internal consistency across multiple cultural contexts, including Arabic-speaking populations, with reported Cronbach’s α values for the total scale typically ranging from 0.80 to 0.88. These findings support the reliability of the CYRM-17 for assessing resilience in diverse cultural settings.
Executive functions
Executive functions were assessed using three computerized tasks administered on iPads through the Gorilla online platform, which ensures high precision in stimulus presentation and reaction-time measurement (Anwyl-Irvine et al., 2020; Cragg and Nation, 2007; Zand et al., 2017). All task instructions were translated into Arabic and validated by a professional translator and community researchers. Each task included a practice phase, and average administration time ranged from eight to 10 min. Standard stimulus sets were used for all tasks, and no reaction-time trimming or outlier removal procedures were applied. Only participants with complete data across all executive function tasks were retained for analysis.
Inhibitory control: Arabic Victoria Stroop test
Inhibitory control was assessed using the Arabic adaptation of the Victoria Stroop Test (A-SV; Kettani et al., 2020). The A-SV has been linguistically and culturally adapted for Arabic-speaking populations and is supported by normative data from multiple regions. The A-SV was validated on a substantial and well-characterized Arabic-speaking sample (N = 359) and demonstrated good reliability and validity, as evidenced by consistent performance patterns across conditions, sensitivity to age and educational level, and stable interference effects derived from regression-based normative modeling. In this validation work, reliability is addressed through performance stability, error distribution analyses, and normative consistency. The task includes three conditions—color naming, word reading, and interference—and yields accuracy and reaction-time indices. An interference error score was calculated by subtracting errors in the word-reading condition from those in the interference condition (Figure 1).
Figure 1. Arabic Victoria Stroop test.
Working memory: N-Back task
Working memory was assessed using 1-Back and 2-Back tasks presented in four sequences. Participants indicated whether the current stimulus matched one presented one or two trials earlier. Performance metrics included accuracy, false alarms, omission errors, and reaction times. Normative comparisons were drawn from a large Spanish dataset (N = 1,032) (Pelegrina et al., 2015), which also provides validation evidence indicating that the N-Back task demonstrates acceptable reliability, supported by stable accuracy and reaction-time patterns across age-stratified samples and consistent performance differences between task loads. Standard stimulus sets were used for all participants (Figure 2).
Figure 2. N-Back task.
Cognitive flexibility: Wisconsin card sorting test
Cognitive flexibility was assessed using a computerized version of the Wisconsin Card Sorting Test (WCST; Monchi et al., 2001). Participants were required to infer and adapt sorting rules based on feedback, allowing computation of total errors, perseverative errors, and categories completed. Perseverative error rates served as the primary indicator of cognitive flexibility. The WCST is a widely used neuropsychological instrument with well-documented reliability, typically established through test–retest stability and consistent sensitivity to executive dysfunction across normative and clinical populations (Chan and Morgan, 2018; Zhao et al., 2013) (Figure 3).
Figure 3. Wisconsin card sorting test.
Learning and perceptions of school
Learning outcomes were approximated using school grades from the current and preceding academic year. Due to variability in evaluation practices within crisis-affected education systems, all reported grades were verified with both students and their parents to ensure accuracy.
Perceptions of school were assessed using items adapted from the Trends in International Mathematics and Science Study (TIMSS) student background questionnaire. These items capture multiple, related dimensions of students’ school experiences, including absenteeism, emotional responses to attending school, perceptions of the school environment, and perceptions of teachers (Arvisais et al., 2026). These domains capture essential components of students’ affective engagement, sense of safety, and perceived instructional support. Responses were collected using Likert-type scales for attitudinal indicators and categorical formats for absenteeism. In the original study by Arvisais et al. (2026), the adapted items demonstrated acceptable internal consistency (Cronbach’s α = 0.60), consistent with their use as exploratory, indicator-based measures. In the present pilot study (N = 6), reliability estimates were not computed, as internal consistency coefficients would be unstable and uninterpretable given the very small sample size.
Analyses
We analyze the relationship among the variables in the study to emphasize the primary effects of the independent variables (stress, resilience factors, and well-being) and the moderating variable (skills related to executive functions) on the dependent variable (learning), as well as their interaction effect. It should be noted that this is a multi-case study. As the sample size is limited, our aim is to create a detailed portrait of each case rather than to perform advanced statistical analyses. To evaluate executive function tasks, we performed standard analyses to quantify each participant’s level of expertise in each executive function. For cortisol, we computed the diurnal secretion curve, cortisol awakening response (CAR), and area under the curve (AUC).
Results
In this section, we present the empirical findings from the six participants, identified by aliases (Abdel, Hamza, Nassim, Mehdi, Youssef, and Omar). For each case, we report exposure to potentially traumatic events, perceived stress, physiological stress markers, well-being, resilience, executive functioning, and school-related indicators.
Table 1 presents the interplay between traumatic experiences and all psychological and physiological indicators collected. The table elucidates individual participant scores in each category.
Table 1. Case study presentation.
As shown in Table 2, we assessed participants’ school perceptions across several constructs, including absenteeism, emotions experienced when attending school, their view of the school environment, their teacher’s perception, and academic performance.
Table 2. Participants’ perception of the school.
Diurnal cortisol secretion
We present each case’s diurnal cortisol secretion pattern. These descriptions are based on typical cortisol curves beginning with a peak shortly after waking (30–45 min) followed by a decline through the day.
As shown in Figure 4, Hamza’s cortisol level begins low upon awakening, increases after 30 min, and continues rising until a peak at 4 p.m., with a slight decrease by bedtime.
Figure 4. Diurnal cortisol secretion of Hamza vs. basal curve.
As shown in Figure 5, Mehdi’s cortisol level increases upon waking and then decreases 30 min later. Levels slightly increase during the day and then decrease before bedtime.
Figure 5. Diurnal cortisol secretion of Medhi vs. basal curve.
As shown in Figure 6, Abdel begins with a low awakening level, increases after 30 min, and continues rising until a peak at bedtime.
Figure 6. Diurnal cortisol secretion of Abdel vs. basal curve.
As shown in Figure 7, Nassim’s cortisol level begins low, increases after 30 min, rises steadily until late afternoon, and declines before bedtime.
Figure 7. Diurnal cortisol secretion of Nassim vs. basal curve.
As shown in Figure 8, Omar exhibits a slightly elevated awakening level, decreases after 30 min, gradually rises through the day, and sharply declines before bedtime.
Figure 8. Diurnal cortisol secretion of Omar vs. basal curve.
As shown in Figure 9, Youssef begins with a relatively low awakening level, shows a marked increase after 30 min, continues rising until late afternoon, and declines by bedtime.
Figure 9. Diurnal cortisol secretion of Youssef vs. basal curve.
AUC-G values and AM/PM cortisol means are presented in Tables 3, 4.
Table 3. Area under the curve in μg/dL.
Table 4. Cortisol range AM & PM.
Cognitive executive functions
Working memory (N-Back)
Table 5 shows descriptive results for all cases. Accuracy in the 2-Back condition was lower than in the 1-Back condition. Omission errors were higher in the 2-Back condition. Reaction times varied across sequences.
Table 5. Descriptive results of the N-Back task for all participants.
Next, Table 6 compares our results with normative Spanish data. p-values for group differences in targets detected or false alarms in the 1-Back and 2-Back conditions did not reach statistical significance.
Table 6. Comparison with normative data for the N-Back task.
Inhibitory control (Stroop)
Table 7 indicates strong performance on the Stroop task: high accuracy across conditions and expected increases in reaction times.
Table 7. Descriptive results for the Stroop task for all participants.
Table 8 compares interference error scores with international normative datasets.
Table 8. Comparison with normative data for the Stroop task.
Interference scores ranged from −1.0 to 9.0 across participants.
Cognitive flexibility
Table 9 presents WCST performance. Several participants showed a high number of errors and perseverative errors.
Table 9. Descriptive results for the Wisconsin task for all participants.
Table 10 compares perseverative error percentages and total errors with Brazilian normative data. A significant difference in perseverative errors (p = 0.009) was observed.
Table 10. Comparison with normative data for the Wisconsin task.
Discussion
Looking at the results, the first thing that stands out is the high exposure to potentially traumatic events in the last 3 months (Table 1). Half of our participants had experienced seven events. With this level of exposure, we could expect an impact on participants’ mental health.
Physiological data from the stress biomarker show that all participants have a non-typical cortisol awakening response (CAR). Our interpretation is based on the study from Chung et al. (2023). In this research, the CAR and potential determinants were evaluated for 69 healthy children aged 6 to 12 years. The objective was to address the gap in knowledge about CAR in children below the age of 10. This study showed that CAR occurs in about 75% of healthy individuals. Furthermore, these findings—particularly prevalent in males—shed light on CAR parameters within a healthy pediatric sample. According to this study, the typical CAR for a healthy child aged 6 to 12 is between 50 and 75%. As reported by Chung et al. (2023). The stability of the CAR is well established in healthy children and adolescents (Bäumler et al., 2013; Platje et al., 2013). Exposure to acute stress is generally associated with an increase in CAR, and chronic, prolonged, uncontrollable, or traumatic stress is associated with an attenuation of CAR (Filaire et al., 2013).
After interpreting our data according to these parameters, only one participant (Abdel) out of six has a cortisol awakening response (CAR) close to the typical threshold (88% for a boy of his age). He is also the least exposed to potentially traumatic events (N = 3) in the period studied. On the other hand, he appears to have lower psychological resilience, lower well-being, and the lowest academic achievement. Being the youngest and the only one experiencing academic challenges may be contributing factors.
Abdel and three other cases under study—Hamza, Nassim and Youssef—appear to be under chronic stress according to their CAR. In contrast, Mehdi and Omar are potentially in a state of stress-related exhaustion. It is noteworthy that both do not show a CAR at all, instead displaying negative values. Based on the parent logbooks and daily verification phone calls, there is no indication that the saliva timing deviated from the required protocol. The self-reported perceived stress data align perfectly with their CAR values, reinforcing this interpretation: both report extremely low perceived stress (5/39).
Our hypothesis is that these two individuals may have difficulty perceiving stress due to reduced cortisol secretion, potentially caused by chronic exposure to the stressors generated by political violence. The alignment between perceived stress and the stress biomarker is consistent across all cases except for Abdel. Regarding the resilience and well-being results, these two indicators correspond seamlessly with one another. It appears that these constructs are comparable or at least progress in a similar manner.
As shown in Table 2, participants generally hold a positive perception of school. They express favorable views of the school environment, feel safe, and evaluate their teachers positively. All students except Abdel have high grades. Abdel again stands apart: he reports more negative emotions when attending school, more frequent absences, lower well-being, lower resilience, and lower academic achievement. The study of his case suggests a strong link between his level of well-being and resilience and the fact that school does not seem to be serving its protective role for him.
Turning to the cortisol secretion patterns, each participant displays unique variations from the typical curve. The absence of a pronounced CAR in most participants, as well as elevated levels in the late afternoon or evening in several cases, may be related to recurring stressful experiences such as encountering soldiers on the way home or hearing almost daily violent clashes, gunfire, and stun grenades in the camp.
According to Rotenberg et al. (2012), typically developing boys aged 9 to 12 should have a diurnal AUC-G around 2.23 (1.18) μg/dL. Nassim, Omar, and Youssef show AUC-G values within the expected range. Hamza and Abdel show higher values, while Mehdi’s is substantially below. Chronic stress, anxiety, or depression are often associated with elevated AUC values (Sapolsky et al., 2000; McEwen, 2008; Ulrich-Lai and Herman, 2009). Research has shown heightened cortisol levels in individuals with major depressive disorder, leading to increased AUC values (Pariante and Lightman, 2008; Stetler and Miller, 2011). Conversely, low AUC may indicate an adaptive response to prolonged stress (Miller et al., 2007; McEwen, 1998; Fries et al., 2005). In acute stress, cortisol typically spikes; with chronic stress, the system may become dysregulated. Over time, the body may adapt by suppressing cortisol production. Overall, cortisol levels in our participants were well below pediatric norms (Griffing, 2020), reinforcing the impression of chronic HPA-axis dysregulation.
In the N-Back task, accuracy decreases in the more demanding 2-Back condition, with an increase in omission errors. Reaction times do not consistently follow the expected pattern of longer latencies in the harder condition. Between sequences 1 and 4, there appears to be a habituation effect followed by a learning or training effect. Comparisons with Spanish normative data (Pelegrina et al., 2015) indicate no statistically significant differences in targets detected or false alarms. None of the tests yielded p-values below 0.05, and our directional hypothesis that the sample would perform below the norm is not supported.
For the Stroop task, accuracy was high across all conditions, though reaction times increased as expected in more complex conditions. Comparisons with normative data from several countries (Moradi et al., 1999; Roy et al., 2018; Guerra et al., 2021; Roukoz et al., 2021; Er-Rafiqi et al., 2022) reveal comparable or slightly better performance. Negative interference scores in some participants (Youssef, Abdel) are unusual and may reflect specific task strategies or low automaticity in reading. The range of interference scores (−1.0 to 9.0) suggests diverse cognitive profiles. Some of these patterns, particularly negative values, warrant further investigation. The small sample size limits statistical power, but the variation nonetheless underscores the need for a nuanced understanding of executive functions among Palestinian children living in contexts of political violence.
The Wisconsin Card Sorting Test (WCST) reveals the greatest difficulty for participants. A large number of errors (55–80%) were observed, and perseverative errors were frequent (44% of the group). Comparisons with Brazilian norms (Coelho et al., 2012) show significantly higher perseverative errors, even though total errors were not significantly different. Perseverative errors are a well-known indicator of impaired cognitive flexibility. This supports the hypothesis that Palestinian children living in chronic instability may face more pronounced challenges in cognitive flexibility than in other executive functions.
Cognitive flexibility plays a pivotal role in learning, problem solving, adjusting to changing task demands, and interpreting social cues (Borst and Houdé, 2014). It influences empathy, conflict resolution, and general social functioning. Our findings suggest that participants may be trapped in a self-perpetuating cycle: the conflict environment diminishes cognitive flexibility, which in turn reduces the ability to resolve conflict, both in school contexts and in daily life. Living in a conflict-ridden environment appears to impair not only the moral capacity to resolve conflicts but also the cognitive capacity to do so.
Conclusion
To the best of our knowledge, no studies have tested the impact of chronic stress, psychological exhaustion, or different types of trauma on children’s executive functions. However, existing literature has consistently suggested that chronic stress have a negative impact on executive functioning. Only a few studies have recently considered the possibility that these states or experiences might improve one or more executive functions. This pertains to Kira et al.’s (2022) study on an adult population and Eren-Koçak and Kiliç’s (2014) pilot study, which suggests that trauma correlates with enhanced executive functioning. For our part, as shown in Table 11, it appears that some of the cases we have studied exhibit cognitive flexibility significantly lower than the average, but slightly above-average working memory, and most notably, cognitive inhibition significantly above the average. Overall, our participants seem to be in a state where they are less easily alarmed and in which it may be easier to inhibit.
Table 11. Cognitive tasks performance metrics.
In conclusion, let us take a step back and examine the overall situation for each cases. Over the past 3 months, the six children under study exhibited varying levels of exposure to potential traumatic events. Abdel demonstrated the least exposure (3 reported events in the last 3 months) while Mehdi, Youssef, and Omar exhibited the most (7 reported events in the last 3 months). Despite their varying degrees of potential trauma exposure, these children displayed high levels of well-being and resilience, even in the face of chronic stress. Measurements of the CAR revealed that certain children demonstrated increased stress responses, whereas others exhibited indicators of stress-related depletion. Importantly, discrepancies between self-reported stress scores and physiological measurements were observed, underscoring the need for a multifaceted approach to comprehending children’s stress experiences. Indeed, our objective data (physiological & performance measures) tell a very different story than self-reported data apart from a single participant. Indeed, Abdel seems to be the only one where all data aligns. We could hypothesize that he’s the one most in touch with his emotions and most able to share how he’s feeling. The participants demonstrated a varied level of performance in executive functions. The results indicated that cognitive inhibition, assessed through the Stroop interference error score, was generally strong. However, performance in working memory and cognitive flexibility showed significant variations. In particular, numerous children exhibited signs of struggling with cognitive flexibility, as revealed by Wisconsin persistence errors. Youssef’s performance in all three executive functions was exceptional, surpassing the normative data. In contrast, Hamza and Mehdi faced distinct cognitive challenges in certain areas. The study sheds light on different facets of children’s responses to trauma, highlighting that perceived resilience and well-being are still high even in the face of challenges. The variation in cognitive abilities highlights the necessity of personalized strategies for meeting the unique requirements and abilities of students who are regularly exposed to political violence. The present study is a multi-case pilot research and further research, with larger sample, is necessary to examine the impact of exposure to political violence or armed conflict on students’ learning abilities in various contexts. Nevertheless, the study allowed us to test a methodological approach and highlight challenges of conducting research in unstable context. Qualitative data could provide valuable insights into culturally informed methodologies, tools, and practices. Moreover, additional research should explore the impact of this exposure on the global health and academic performance of affected populations. Finally, our findings suggest that the effectiveness of pedagogical interventions tailored to the individual needs of students should be evaluated.
Data availability statement
The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.
Ethics statement
The studies involving humans were approved by the Institutional Review Board of the Université du Québec à Montréal (UQAM) (approval no. 4271e2020) and by the Helsinki Committee of the Palestinian Health Research Council (approval no. PHRC/HC/1217/22). The studies were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin. Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.
Author contributions
AJ: Formal analysis, Investigation, Software, Validation, Writing – original draft, Writing – review & editing. OA: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing.
Funding
The author(s) declared that financial support was received for this work and/or its publication. This research was supported by the Social Sciences and Humanities Research Council of Canada (SSHRC), grant number 430-2022-00839.
Conflict of interest
The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Generative AI statement
The author(s) declared that Generative AI was not used in the creation of this manuscript.
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Keywords: cognitive functioning, learning in emergency, occupied Palestinian territories, psychosocial well-being, stress and resilience
Citation: Joma A and Arvisais O (2026) Stress, resilience, and learning in emergency: a multi-case study of children’s well-being and cognitive functioning in a West Bank refugee camp. Front. Educ. 10:1742975. doi: 10.3389/feduc.2025.1742975
Edited by:
Elizabeth Fraser Selkirk Hannah, University of Dundee, United KingdomReviewed by:
Sayed Jafar Ahmadi, Bard College, United StatesMarta Prucnal-Wójcik, Ignatianum Academy in Krakow, Poland
Copyright © 2026 Joma and Arvisais. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Amjad Joma, YW1qYWQuam9tYUBhc3UuZWR1Lm9t
†ORCID: Amjad Joma, orcid.org/0000-0002-2605-1987
Olivier Arvisais, orcid.org/0000-0003-4494-1278