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Shechory, M., Ben-David, S., & Balahur, D. (2008). Children and youth reactions to
acute and continuous external stress – terrorist attacks. In: D. Balahur (Eds.).
Children's rights to education and information in a Global World. (pp. 79-96).
Romania: Alexandru Ioan Cuza University of Iasi.
Children and youth stress reactions to acute and continuous external
stress – terrorist attacks.
Mally Shechory, Ben-David Sarah1, Balahur Doina2
In recent years, terrorism has become a daily reality affecting people around the
world. Thousands of civilians have been killed and injured by terrorist attacks in the
last decade, many of whom were children. It is well known by now that terror is a
major stressor that is faced by millions around the world and that has an impact on
nations, communities, and individuals. The increase of terror attacks and fear of terror
in the last decade and the extensive exposure it has received enhanced the interest of
researchers in the implications and outcomes of terror, and brought about a significant
rise in the amount of research conducted on these issues. As children are different
from adults in many ways, it is essential to understand children's reactions to this type
of stressor, to define the needs of children, to plan for their care and to ensure optimal
management of children at risk. This paper will review the current literature in the
field of children’s stress reactions to terrorist attacks as acute and continuous external
stress, and examine the variables that were found as intensifying the stress reaction
and those that were found to have preventive or protective powers. The purpose of
this paper is to describe the outcome of the exposure of children and youth to terror
attacks. We believe that such a description will highlight the problems and the need
1
2
Ariel, University Center of Samaria and Bar-Ilan University, Israel
Al.I.Cuza University, Romania
2
for treating this unique population, and help professionals to develop appropriate
services for this purpose.
Introduction
In 1980, when Posttraumatic Stress Disorder (PTSD) was first included in
psychiatric diagnostic guides, the American Psychiatric Association described it as
being the result of events that occur outside the range of normal human experience.
Unfortunately, this definition does not appear to be accurate. Traumatic events are
indeed out of the ordinary experiences, not because they occur infrequently, but
because in many instances they inhibit regular human adaption to life (Herman,
1992). Reality indicates that in a significant number of places around the world people
are exposed to terror events both directly and indirectly, and it is difficult to define
these events as being outside the range of normal human experience.
Violence resulting from political, ethnic and religion-based wars is a worrying
and ever burgeoning phenomenon around the world (Gurr, 2000; Harvey, 2001;
Horowitz, 2001). In recent decades we have been witness to armed conflicts that tend
to be ongoing and to take place in civilian population areas. The examples are many
and include: Israel, the Palestinian Authority, Lebanon, Croatia, Bosnia, Rwanda,
Cambodia and Iraq. In this kind of reality, where there is no clear differentiation
between the front line and the home front, harming civilians is unavoidable.
Especially grave are numerous war crimes, acts of terror, crimes against humanity and
acts of genocide that are committed against children and adolescents.
A United Nations report (2003) indicates that in the past fifteen years, some
two million children have been killed in conflict situations; that over six million have
3
been injured or are suffering from permanent injuries or disabilities; more than a
million have been orphaned and millions more have been uprooted from their homes.
Some children have even been enlisted into taking part in the battles themselves, and
others have been sexually abused.
In her book “Children and Armed Conflict”, Harvey (2001) describes the
horrifying reality of sexual exploitation of girls who are turned into sex slave as well
as the exploitation of adolescents who are forced to serve as “soldiers for all intents
and purposes” (See also: De Silva, Hobbs, & Hanks, 2001).
Numerous studies point to the pathogenic effects of exposure to terror events.
The present chapter will deal with these effects on children and adolescents and refer
to the various factors found to impact the intensity of the trauma experienced as a
result of exposure to these events.
Terror, PTSD and Emotional Stress
The word terror entered the West’s political vocabulary following the actions
of the French revolutionaries against their domestic enemies (in 1793-1794). It
referred to governmental repression, most directly in the form of executions
(Connolly, 2003; Tilly, 2005). However, since the French Revolution, the word terror
has expanded in scope, and has been used to describe a variety of violent acts, such as
direct and indirect physical harm, the use of biological technologies and attacks on
centers of power and national symbols (Fullerton, Ursano, Norwood & Holloway,
2003; North & Pfefferbaum, 2002).
Since 1983, the United States Code [Section 2656f(d)] (U.S. Department of
State, 2000) defined terrorism as premeditated, politically motivated violence
perpetrated against noncombatant targets (civilian populations, who are not military
members. It includes military members who are attacked during peace time) by
4
subnational groups or clandestine agents, usually intended to influence an audience
(Ruby, 2002); to create extreme fear and anxiety among an audience, beyond the
immediate victims (Jones & Fong, 1994; Oots, 1990).
However, a specific event is not necessarily easy to define or identify as an act of
terrorism. As a result, minor differences in the way violent events are described in the
media may influence whether they are perceived and remembered as acts of terrorism
or acts of patriotism (Dunn, Moore, & Nosek, 2005). It is claimed by some that
defining terrorism is a subjective task (Ruby, 2002; Schaffert, 1992; Shamir &
Shikaki, 2002).
A good example is the subjective view of the Israeli-Palestinian conflict. For the
Israeli society, each suicide attack that occurred during the Intifada (Palestinian
uprising) was perceived as the severest kind of terror attack. On the other hand, the
suicide bombers who perpetrated these acts were perceived by the vast majority of the
Arab Palestinian public as “shaheeds” and “holy martyrs” who acted out of purely
altruistic motives.
These definitional variations suggest that identifying terrorism is a motivated
process that distinguishes justified acts of violence committed by the ingroup from
unjustified acts of violence committed by outgroups (Dunn, Moore, & Nosek, 2005).
However, this does not change the fact that acts of terror sow destruction, and
exposure to terror events is perceived as a traumatic event. At the same time, the
advance of research in the field of trauma in recent years led many researchers to
believe that the term “traumatic event” is too general a term. It includes different
events and situations that do not always share a common denominator and includes a
broad range of aspects (Ehrenreich, 2003; Fullerton, Ursano, Norwood, & Holloway,
2003). Ehrenreich (2003) noticed that using the single term "psychological trauma" to
5
describe people's emotional responses to horrific events such as natural disasters, war,
physical abuse or motor vehicle accidents, is deeply problematic. This sentence is
particularly relevant when applied to the impact of terror on children and adolescents.
Although a survey of the literature (for a review see: Freemont, 2004) points to
similarities in the emotional responses of children following exposure to terror events
when compared to other traumatic events such as rape, physical abuse and natural
disasters, terror events are nevertheless different from several aspects. Terror events
are always unexpected. Their objectives are to intentionally cause harm, to spread fear
and to disrupt the lives and routines of individuals and communities. In many
instances it constitutes an ongoing and unending reality. These events result in direct
victims—those killed and injured and their families, and indirect victims—the
audience that is exposed to visual and other descriptions of the event in the media and
who experience fear of the unknown. Sometimes the very existence of the threat of
further terror attacks is sufficient to create a state of ongoing trauma (Susser, Herman
& Aaron, 2002). Posttraumatic stress disorder is a very common psychiatric disorder
that appears as a result of exposure to traumatic events that include terror events
(Stuber et al, 2002; Pfefferbaum et al, 2000)
According to the DSM-IV TR (APA, 2000) posttraumatic stress disorder follows
exposure to events that include threat, danger or a real possibility of death or severe
injury for an individual or those around him. This distinction is based on the fact that
the person has been exposed to a traumatic event and the individual’s subjective
experience of fear, horror and sense of helplessness. The post-traumatic reaction is
characterized by three groups of symptoms suffered by the individual affected by this
disorder: persistent re-experience of the traumatic event; persistent avoidance of
stimuli associated with the trauma; and persistent symptoms of increased arousal. The
6
duration of the disturbance needs to be more than one month. In addition, the
disturbance causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning. In addition, there are specific diagnostic
criteria that describe symptoms that might appear among children and adolescents.
For example, young children re-experience the traumatic event through repetitive play
in which themes or aspects of the trauma are expressed. In addition, in children, there
may be frightening dreams without recognizable content. This is in contrast to adults
who report nightmares connected to the traumatic events that they experienced.
Clinicians and other professionals who work with survivors have noted that the
symptom patterns observed after traumatic events are more complex than those
encompassed by the PTSD category (Ehrenreich, 2003; Herman, 1992; Johnsen, Eid,
Laberg, & Thayer, 2002). Studies point to an additional range of symptoms that
indicate stress that includes depression, anxiety, hostility, social alienation, decreased
cognitive abilities and somatization. In general, exposure to terror events and violence
related to political conflicts are associated with posttraumatic symptoms and
psychiatric distress (Baker, 1990; Derogatis & Spenser, 1982; Ronen, Rahav &
Rosenbaum, 2003; Thabet, Abed & Vostanis, 2002).
Risk factors of posttraumatic symptoms and psychiatric distress
Events such as terror and war (Ronen, Rahav & Appel, 2003; Garbarino, Kostelny &
Dubrow, 1991; Garbarino & Kostelny, 1996) and a range of other violent politicallyrelated events (Slone, Kaminer & Durrheim, 2000; Slone, Adiri & Arian, 1998) were
all found to have a negative effect on the well being of children and youth. When
they are involved in hostilities, they face enormous risk to their physical, social and
emotional well being, and they may suffer long lasting psychological damage. Studies
7
that examined the emotional impact of terror events and war on victims indicated a
number of important characteristics, such as the victim’s age and gender, the level of
exposure, physical and psychological proximity and the sense of threat experienced
by the victim (Chimienti, Nasr & Khalifeh, 1989; Hallis & Slone, 1999;
Schwarzwald, et al, 1994; Slone, Lobel & Gilat, 1999).
Studies that deal with the connection between the victim’s age and his reaction to
exposure to terror events and political violence revealed conflicting findings. Some
researchers indicate that the younger the age of a child, the risk of developing
psychological disorders as a result of exposure to traumatic events increases (AlKrenawi, Graham & Slonim-Nevo, 2002; Cannetti et al., 2000; Salmon & Bryant,
2002).
Norris et al (2002) claim that young children are at higher risk than
adolescents and adults. Solomon (1993) explains that the reason for higher
vulnerability among young children might be due to immature cognitive abilities and
copies skills. However, specifically because children are not always able to fully
comprehend the level of danger they are in, their inability to identify dangerous
situations constitutes a protective factor against developing symptoms of trauma; as it
is known that perceiving an event as threatening and dangerous is an important factor
in the implications of a traumatic event. As aforementioned, research findings are
conflicted. While some researchers regard the victim’s age as a differentiating factor
(Norris et al, 2002; Pynoos, R. S., Kinzie, J. D., & Gordon, 2001;Saigh et al, 1999;
Salmon & Bryant, 2002), others found no differences between children and
adolescents (Allwood, Bell-Dolan, & Husain, 2002) or found that older children
demonstrated higher levels of posttraumatic stress syndrome (Nader et al, 1993).
Studies on posttraumatic reactions indicate that both children and adolescents
suffer from symptoms such as avoidance, re-experiencing and overarousal. However,
8
the manifestation of these symptoms to a large extent overlap with the victim’s
developmental stage. Small children under the age of five will in most cases
demonstrate symptoms that indicate developmental regression, such as bedwetting,
finger-sucking, fear of separation, phobias—mainly of darkness, nightmares and a
temporary lapse in developmental skills (Fremont, 2004; Scheeringa, Zeanah &
Larrieu, 1995) (See also: review in Davis & Siegal, 2000). Among older children of
school going age researchers found manifestations of fear that were not necessarily
connected to the traumatic event (such as fear of the dark, fear of showering alone,
etc.), somatic complaints, restlessness, difficulty in coping with frustrations, social
regression, impaired concentration and memory, lower learning achievements, high
incidence of involvement in risk-taking behavior such as the use of addictive
substances, expressions of violence and anti-social behavior (Laor, Wolmer, Alon,
Siev, Samuel & Toren, 2005; Qouta, Punamaeki & El-Saraaj,1995a, 1995b;
Scheeringa, Zeanah, & Larrieu, 1995; Show, 2000; Yule, 2001). For example,
Walton, Nuttall and Nuttall (1997) found that half of the twelve-year-old children
who were exposed to the civil war in El Salvador suffered from posttraumatic
symptoms such as sleep disorders and nightmares, psychosomatic symptoms,
impaired concentration and memory function, etc.
From the findings of the abovementioned studies it is difficult to determine
irrevocably that young children are more affected by and are more vulnerable to
posttraumatic reactions when compared to adolescents, or vice versa. Nonetheless,
researchers agree that the reaction of younger children is connected to and influenced
to a large extent by the reaction of his environment, more specifically of his parents
(Shaw, 2003). Ajdukovic and Ajdukovic (1998) noted that the type of interaction in
the family has a significant influence on children’s reactions to traumatic experiences.
9
Researchers found that high levels of depression were found to be mainly connected
to the mother’s ability to adapt and to the extent of change in her relation to the child.
Similarly, studies indicate that children who sense the anxieties and pressures that
affect their parents demonstrate high levels of anxiety, develop phobias and suffer
from nightmares. It appears that the overall family atmosphere and the parents’
methods of coping with stressful situations significantly impact the level of anxiety
experienced by their children (Punamaki & Sulieman, 1990).
With regard to the impact of the gender of the victim on the severity of emotional
reactions, most studies found that girls, more than boys, showed symptoms of fear,
anxiety, re-experience, overarousal and accompanying distress such as depression and
somatization (Durkavic-Belko, Kulenovic & Dapic, 2003; Giaconia et al, 1995;
Klingman, 1992; Kuterovac, Dyregrov & Stuvland, 1994; Ronen, Rahav &
Rosenbaum, 2003; Vizek-Vidovic, Kutervac-Jagodic & Arambasic, 2000). In
comparison, greater distress among boys was manifested by social dysfunction and
primarily by a tendency toward dangerous behavior (Shaw, 2003). There is a general
tendency to regard girls as a group given to higher risk compared to boys. Even so, it
is important to note that several studies found no gender differences in reports on
posttraumatic reactions as well as findings that were ambiguous (Allwood, Bell-Dolan
& Husain, 2002; Schwarzwald et al, 1993).
It appears that the victim’s age and gender has a significant effect on the way the
individual reacts when exposed to terror events and to traumatic events in general.
Even so, there is no doubt that the general picture is far more complex, as mentioned
above, and one must also take into account those factors that characterize the event
itself. Studies indicate more severe harm and a far higher traumatic impact in cases of
direct exposure to terror events and in cases that involve personal involvement or
10
close proximity to the scene of the event (Pfefferbaum et al, 2003; Schwartzwald,
Weisenberg, Waysman, Solomon & Klingman, 1993, 1994; Stuber et al, 2002).
For example, Vizek-Vidovic, Kutervac-Jagodic and Arambasic (2000) found that
children and adolescents (aged 8-16) from Croatia who were highly exposed to
traumatic events during the war suffered from a higher level of posttraumatic
symptoms compared
to children who were minimally exposed. Another
comprehensive study conducted in Israel following the al-Aqsa Intifada, as part of an
extensive project for the early location of posttraumatic distress and stress symptoms,
among adolescents (aged 13-18) who reported personal exposure to terror (37.8% of
the subjects were involved in terror, were injured or had a relative who was injured),
there was a higher incidence of posttraumatic symptoms, sense of fear, sense of
hopelessness, despair, more severe functional impairment and many more symptoms
of depression and somatic symptoms compared to subjects who were exposed to
terror through the media, including television. Similarly, another study that examined
the connection between exposure to terror events and posttraumatic symptoms among
2,999 children and adolescents living in various parts of Israel, a positive connection
was found between the number of terror events they were exposed to and
posttraumatic symptoms (Laufer & Solomon, 2006).
Even so, both children and adolescents who were exposed to terror events
through the media demonstrated a degree of emotional distress following indirect
exposure. Studies conducted after the attack on the Twin Towers indicated a high
level of distress among people who do not reside in New York or in the proximity
thereof (Cohen-Silver, Holman, McIntosh, Poulin & Gil-Rivas, 2002; Schlenger,
Caddell, Ebert, Jourdan & Batts, 2002).
11
For example, Schuster et al (2001) found that 35% of children had one or more
stress symptoms, and 47% were worried about their own safety or the safety of their
loved ones.
After one to two months following the events of September 11, Schlenger and
his colleagues (2002) found that children appeared to be most upset. They had
difficulty sleeping, were irritable, grouchy, or easily upset, and feared separation from
parents. Other studies reported estimations that 5%-11% of children and adolescents
suffered from posttraumatic stress disorder following indirect exposure to events like
those of 9/11 and the Oklahoma City bombing (Hoven et al, 2002; Pfefferbaum et al,
2003).
The intensity of individual reaction also depends on subjective aspects of the
exposure. Studies show a positive connection between the threat level on the
individual’s life and his surroundings and psychiatric and posttraumatic symptoms
among both children and adolescents. Events that include loss, violence and
displacement were found to be the ones with the most significant impact (Aziz,
Thabet & Vostanis, 1999; Punamaki, Qouta & El-Sarraj, 2001; Tulin, Behiye,
Osman, Nimet & Melek, 2003).
For example, Macksoud and Aber (1996) were found that children and
adolescents from Lebanon (aged 10-16) who were directly exposed to violence or
who were kidnap victims suffered from long-term posttraumatic stress disorder.
Papageorgiou et al (2000) found that among children aged 8-13 who were exposed to
the events of the war in Bosnia-Herzegovina, and who were the mainly from refugee
families or had lost at least one parent, some 47% suffered from clinical depression.
Additional studies also point to high percentages of psychiatric problems among
children and adolescents who were uprooted from their homes, to intrusive thoughts,
12
avoidance responses, etc, compared to children who remained in their homes
(Kutervac, Dyregrov & Stuvland, 1994).
A review of the comprehensive literature referred to above teaches that situations
of political violence and exposure to terror have a negative impact on the emotional
welfare of children and adolescents, on their behavior, their emotions and on their
cognitive perceptions. Some of the studies point to long term symptoms while others
report a significant decrease in the frequency and intensity of the symptoms (e.g.
Dyregrov, Gjestad & Raundalen, 2002; Smith et al, 2002; Thabet & Vostanis, 2002).
At the same time, some researchers also point to the positive connection between
symptoms of posttraumatic stress and posttraumatic growth (e.g. Laufer & Solomon,
2006). Posttraumatic growth is defined as the tendency to report significant positive
changes in self-perception, in worldviews and in interrelations with others following
a traumatic event, and refers to several areas in which improvement or development is
visible in the aftermath of a traumatic event. Examples include a closer connection to
others, identifying new life options, a sense of personal empowerment, spiritual
reinforcement and a renewed and more positive view of life (Tedeschi, 1999;
Tedaschi & Calhoun, 1996). Until recently, numerous researchers tended to examine
distress as an aftermath of a traumatic event while ignoring the possible positive
influences of the event. However, there are scientific testimonies to the existence of
the positive, as well as the negative, aspects of traumatic events (Collins, Taylor &
Skokan, 1990; Lehman, et al, 1993: Park et al, 1996; Solomon & Lavi, 2005).
In a comprehensive study, Laufer and Solomon (2006) found that the rate of the
appearance of posttraumatic symptoms among Israeli adolescents is lower than that
reported in some off the research conducted on children in other countries. Moreover,
the researchers note that 74% of the subjects also reported a sense of growth, and that
13
a positive and significant connection was found between symptoms of posttraumatic
stress and growth. The researchers explained the relatively moderate rate of
posttraumatic stress symptoms among young Israelis and their feelings of growth as
being connected to environmental stability and the economic situation in Israel. Other
regions where studies were conducted were rife with social unrest and poverty and
even total breakdown of the social structure, and children in these regions suffer from
higher rates of posttraumatic symptoms (Allwood, Bell-Dolan, Husain, 2002; Walton,
Nuttall, & Nuttall 1997). In addition, there is indication that children exposed to
ongoing stressful conditions, particularly if they are not directly affected, tend to
adapt to the situation, thereby lowering the level of the distress experienced with each
event (Ronen, Rahav & Appel, 2003; Miller, 1996; Pat-Horenczyk, 2004; Punamaki,
1996).
An example of continued exposure to terror events is the situation in Israel. Since
September 2001 the lengthy Israeli-Palestinian conflict took an increasingly bloody
turn with the armed Palestinian uprising known as the al-Aqsa Intifada. Terror attacks
included random shooting into crowds and at passing vehicles or individuals, suicide
bombers, car bombs, stabbings and stone throwing. The frequency of these attacks
was not steady during the period. Weeks could pass with no attack, followed by a
week in which 3 attacks would take place. Many people were injured or killed,
including children and adolescents involved in various terror events. Uncertainly and
fear of terror attacks affected the entire Israeli society, including children and
adolescents. In a comprehensive study (2187 subjects) conducted by Pat-Horenczyk
(2004), in which she examined adolescents and children who were exposed to
repeated traumatic events that took place in Israel from 2000-2004, it was found that
60% of adolescents reported feelings of fear, helplessness and despair. However, only
14
4.3% of the subjects met the criteria for full posttraumatic stress disorder (according
to the DSM scale), that includes functional dysfunction as an essential criterion for
this diagnosis. 4.8% suffered from partial symptoms of re-experiencing, avoidance
and over arousal, and the level of distress reported by the subjects testified to a low
rate of depression, somatic complaints and functional dysfunction. Findings from this
comprehensive and other studies conducted in Israel in recent years indicate that in
spite of the high terror level that the youth in Israel are forced to cope with, the level
of posttraumatic damage is relatively moderate. Moreover, most adolescents report a
sense of growth as an aftermath of difficult situations. These findings indicate the
high importance of understanding the factors that contribute to the ability of an
individual to find positive aspects even in the harshest of stressful events.
To summarize, in the present chapter an attempt was made to review the literature
that deals with the impact of terror events on children and adolescents. The review
shows that the effect of trauma on the human condition is complex, and the wealth of
research and findings, some of which is contradictory, emphasizes the complexity of
the subject. The progress of research in the field of trauma in recent years have caused
many researchers to conclude that the term “traumatic event” is too general, and that
it includes different occurrences that do not always necessarily share a broad common
denominator and is comprised of a broad range of aspects (Fullerton et al, 2003).
As well as similarities between the effects of terror and political violence on
children and adolescents in various parts of the world or following exposure to
different types and levels of war and political violence, we also see many differences.
The differences derive, inter alia, from the unique characteristics of the individual
event, country and social environment. Unfortunately, we are not in a position to
15
influence the degree of exposure to traumatic events in general, and to terror events
specifically. However, it would be appropriate to conduct further and more in-depth
studies on the dimensions that are likely to moderate the connection between exposure
to terror events and the symptoms of posttraumatic stress disorder.
16
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