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Terrorism’s Toll on Mental Health: Kids Who Can’t Play, Teen Alcoholics

May 20, 2004
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The 10-year-old boy’s dark eyes widen and he shifts nervously in his seat. He has trouble falling asleep many nights, says he doesn’t feel safe outside of his home and never watches the TV news after a terrorist attack.

It’s been this way since a pair of Palestinian terrorists sprayed shoppers with automatic gunfire outside the bus station in the northern town of Afula more than three years ago. Among those running for their lives were his parents.

The boy found out about the attack while watching the news and was stunned to see footage of his father being taken away from the scene in an ambulance.

“I’m scared it will happen to me,” says the boy, who is one of numerous students receiving trauma counseling at a new school-based treatment program for victims of terrorism.

On the other side of the political divide, a 12-year-old Palestinian boy in the Gaza Strip trembles constantly and finds eating and sleeping difficult ever since an Israeli bomb fell on his house, killing his sister and spraying pieces of her flesh on the walls.

With no end in sight to the violence and uncertainty of the Palestinian intifada, researchers are finding high levels of post-traumatic stress disorder among Israeli and Palestinian children.

This week, Herzog Hospital’s Israel Center for the Treatment of Psychotrauma, in Jerusalem, and the UJA-Federation of New York are holding a conference to examine the effects of terrorism on children and adolescents in Israel and the United States.

About half the children in Jerusalem, the city hit hardest by Palestinian violence during over the past three and a half years, experience symptoms of post-traumatic stress disorder, according to one Israeli child psychiatrist. That’s two to three times higher than the rate of children suffering from other causes of trauma.

A recent study by Herzog’s trauma center found that 33 percent of Israeli youth have been affected personally by terrorism, either by being at the scene of an attack or by knowing someone injured or killed by terrorists. Seventy percent of those surveyed reported increased subjective fear or hopelessness.

The rate of post-traumatic stress disorder among Palestinian children is about 70 percent, other researchers say.

These figures have prompted psychologists to ask how children are affected by growing up in the midst of violence, and how these Israeli and Palestinian youngsters can best be treated and taught to cope.

Many suffer acute anxiety of public transportation and public places. Others have problems with insomnia. Increasingly, behavioral problems are emerging at school.

“The impression is that the rates are higher because terror exposure in Israel is not just a one-time event, but a way of life,” said Dr. Esti Galili-Weisstraub, who heads Hadassah Hospital’s child psychiatry unit and has helped open two clinics in Jerusalem for children suffering from post-traumatic stress disorder.

She presented her findings at a recent Hadassah conference in Jerusalem.

With every new terror attack, she said, past traumas are relived and this “raises the question of the responsibility of the state not to take it lightly that children are exposed to terror trauma.”

In Palestinian areas, even more children witness violence first-hand. On average, every Palestinian child has witnessed about 10 traumatic incidents, according to some Israeli researchers.

“We found the Palestinian children are in a terrible situation . . . showing the range of symptoms of post-traumatic stress disorder, such as not sleeping, being hyper-vigilant, agitated, having nightmares,” said Zehava Soloman of Tel Aviv University. “When you see traumas, and then the hunger and poverty, future orientation is catastrophic: They do not see themselves growing up.”

Post-traumatic stress disorder is a psychiatric disorder that can be triggered after experiencing or witnessing a life-threatening event, from military combat to terrorism, natural disasters and personal assaults.

After the event, day-to-day life can be marred by nightmares and flashbacks, difficulty sleeping and emotional withdrawal.

Children suffering from the disorder often cannot imagine a future in which they are grown up, according to a study of 1,500 children that Solomon helped conduct among West Bank Palestinians, Israeli Arabs and Jewish Israelis in Jerusalem and in settlements in the Palestinian-populated territories.

“Kids feel they have nothing to lose because life is so fragile,” she said.

Another study of some 3,000 Jewish children in Jerusalem and settlements found that being raised with a strong sense of religion and ideology can help foster resilience.

Nevertheless, Miriam Shapira, who directs an emergency crisis center for West Bank settlers, said the situation among settler children is dire.

Almost every school has students who have experienced close losses. One school had 20 students who had lost a parent in terrorist attacks, she said. About half of the teachers also have had a close relative killed or were themselves involved in an attack.

“The culture in settlements is changing,” she said. “Now there is less denial. People are talking about the effects of living with terrorism.”

Researchers say that teenagers are at increased risk of psychological disorders because — at an age where they’re supposed to feel increasingly independent — terrorism places more and more restrictions on where they can go and what they can do.

Additionally, many teens with problems fall through the cracks because they don’t want to burden their parents with their problems.

At this week’s conference on treating traumatized children and adolescents, new research by Dr. Ruth Pat-Horenczyk of the Israel Center for the Treatment of Psychotrauma showed an increase in risk-taking behavior in adolescents exposed to terrorism.

In her survey of 300 Israeli adolescents, about 50 percent reported use of alcohol, with the number rising to 90 percent among those suffering from post-traumatic symptoms. Some 16 percent reported driving recklessly, with the number doubling for those experiencing post-traumatic disorders.

“In a way, they say to themselves what is considered not dangerous — such as taking a bus to school — has now become fatal, so maybe drugs and sex are not dangerous. The borders of danger and non-danger have collapsed,” Pat-Horenczyk said.

The Gaza Strip has seen some of the most intense violence during the intifada.

The Gaza Community Mental Health Program treats some 5,000 children a year in outreach programs in schools and neighborhoods. Program surveys found that a third of Gazan children suffer from post-traumatic stress disorder, and most of the others exhibit some symptoms of disorder as well.

Eyad el Sarraj, who heads the program, says the most dominant theme seen in the children they treat is morbidity and death.

“It is very damaging and creates a new kind of culture — this kind of talking and thinking about death,” el Sarraj said. “Children subjected to certain experiences will continue to have negative feelings unless they are treated.”

Meanwhile, at Alumim Elementary School, located in a working-class neighborhood of Afula, Israeli children exposed to terrorist attacks are getting help.

In a lavender-and-lemon-colored room called “cheder cham,” Hebrew for the “warm room,” children undergo sessions with the school psychologist and other therapists in which they talk about the traumatic episode and learn to process and cope with the trauma.

One boy says the room is so soothing that “it feels like a bath.”

Teachers who have been trained to help children cope with terrorism and launch discussions in their classes following major terrorist attacks also come to the room. They discuss the stresses they face in the classroom as a result of intifada-related violence.

“Teachers are getting better at seeing the symptoms of the children or those at risk,” said the school’s psychologist, Anna Slavin. “They are doing work they never did before, the work of psychologists.”

Esther Cohen, head of the child clinical-psychology program at Jerusalem’s Hebrew University, recently wrote a book on school-based interventions for mass trauma.

She said the idea of a school being a therapeutic center is quite new, but apparently is effective. School has become a place where children can express their fears in a responsive setting and where those struggling with symptoms of post-traumatic stress disorder can be identified.

Cohen’s current research focuses on children aged three to seven who have been directly affected by a terrorist attack.

“The bad news is that we see children who are either very anxious, very depressed or sadistic, having acting-out kind of tendencies,” Cohen said.

Because the children are so young, post-traumatic stress disorder is best detected through play therapy, not the assessment questionnaires used for older children and adults. In the play therapy, the children re-enact a traumatic act they witnessed, such as a bus bombing.

Often, the children will play with an animal or monster trying to get on a bus. Some children depict their homes surrounded by fences or homes with no windows, just holes from which to shoot weapons.

As disturbing as these images are, Cohen says the children we should worry about most are the ones who are so traumatized that they have forgotten how to play at all.

“They cannot engage,” Cohen said. “The essence of childhood is playfulness, and they cannot play.”

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