Understanding terror and violence in the lives of children and adolescents

Grete Dyb, Miranda Olff
Understanding terror and violence in the lives of children and adolescents


Understanding terror and violence in the lives of children and adolescents

This paper is part of the Special Issue: Understanding terror and violence in the lives of children and adolescents. More papers from this issue can be found at http://www.eurojnlofpsychotraumatol.net

Published: 2 July 2014

European Journal of Psychotraumatology 2014. © 2014 Grete Dyb and Miranda Olff. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 Unported (CC BY 4.0) License (http://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.

Citation: European Journal of Psychotraumatology 2014, 5: 25121 - http://dx.doi.org/10.3402/ejpt.v5.25121


Millions of children each year are exposed to acute events that affect one individual or family at a time (e.g., car accidents, residential fire, street violence, sudden medical events) (Langeland & Olff, 2008). Less frequent, but with major impact, are terror attacks. Across the world, terrorist groups, single actor terrorists, and perpetrators of school shootings have attacked groups of children and youth in spaces thought to provide safety. Research performed after such attacks suggests that the prevalence of posttraumatic stress reactions among persons with high levels of exposure is substantial (Schwarz & Kowalski, 1991; Scrimin et al., 2006).

This issue of the European Journal of Psychotraumatology focuses on recent major shooting events targeting youth in Europe. In Finland two shootings took place; the first school shooting occurred in Jokela 2007 and the second in Kauhajoki 2008. After the 2007 school shooting in Finland, high levels of posttraumatic distress were reported by 27% of females and 7% of males, 4 months after the shooting (Suomalainen, Haravuori, Berg, Kiviruusu, & Marttunen, 2011). In this issue, Turunen presents how attachment may be associated with the recovery processes following these events (Turunen, Haravuori, Punamäki, Suomalainen, & Marttunen, 2014).

Recently, the July 22, 2011, Norway terrorist attack horrified the world. Survivors of the shootings at Utøya were interviewed 4–5 months after the attack, and 47% had developed either “full posttraumatic stress disorder (PTSD)” or “partial PTSD” (Dyb et al., 2013). The horror of the events also spread to communities around Norway. Thoresen, Aakvaag, Wentzel-Larsen, Dyb, and Hjemdal (2012) reported strong immediate emotional responses, particularly sadness and a feeling of unreality, in the general population in Norway in the aftermath of the events. While Thoresen et al. found that PTSD reactions were elevated in ethnic minorities, in this special issue Nordanger et al. (2014) suggest that terror may have a more destabilizing impact on victims who have experienced prior adversities, in relation to their peers in college.

Another important issue addressed in this issue is that in communities struck by terror attacks, health care providers immediately are challenged by the question of how to adequately respond. Under-treatment and unmet needs among survivors have been repeatedly documented (Brewin et al., 2010) and can cause unnecessary suffering in survivors. Unfortunately, the question of how to ultimately respond is not fully resolved (Bisson, 2014). There is still little research on the efficacy of very early interventions and what does exist is largely evidence-informed rather than evidence-based. However, doing nothing to support victims of acute traumatic events is not an attractive option.

In this special issue, Nancy Kassam-Adams’ paper presents a framework for thinking about the design, delivery, and evaluation of early interventions for children who have been exposed to different kinds of acute trauma (Kassam-Adams, 2014). She points at targets for early intervention and describes the next steps for research and practice.

Five early intervention principles have been proposed: promoting a sense of safety, calming, a sense of self- and community-efficacy, connectedness and hope (Dückers, 2013; Hobfoll et al., 2007). Many recent early responses to major traumatic events have been guided by these principles, but the designs of actual outreach programs are heterogeneous. In this issue, two different outreach programs are presented. The Finish model mainly focused on outreach organized and administered at one site (Turunen, Haravuori, Pihlajamäki, Marttunen, & Punamäki, 2014), while the outreach to survivors and families in Norway was based on local resources in survivors’ municipalities (Dyb, Jensen, Glad, Nygaard, & Thoresen, 2014). Both outreach programs were based on proactiveness and provided resources for a longer period of time.

In Norway, outreach to school children was provided through an initiative from educational authorities, and in this issue, Schultz, Langballe, and Raundalen (2014) point out the difficulties children might have in understanding what happened and the teachers’ role in explaining acts of terror and establishing a sense of safety.

There remain many challenges to be addressed in preventing PTSD and other difficulties related to acute traumatic events. For obvious reasons, research in these highly unexpected situations may be very challenging and systematic observations are difficult to conduct. It is highly relevant to focus on ethical issues, and targeting victims of trauma for multiple enquiries by researchers should be avoided. Immediately after the terror attack in Norway, a coordinating initiative for research groups was established to promote collaboration between researchers and to protect victims from additional strain (Refsdal, 2014).

This issue is a reflection of the “ISTSS global meeting” organized by the Norwegian Center for Violence and Traumatic Stress Studies (NKVTS, nkvts.no) and the International Society for Traumatic Stress Studies (ISTSS, www.istss.org), in close collaboration with its European counterpart ESTSS (www.estss.org).

Grete Dyb
Norwegian Centre for Violence and Traumatic Stress Studies
Norway and Institute of Clinical Medicine
Faculty of Medicine, University of Oslo
Email: grete.dyb@nkvts.unirand.no

Miranda Olff
Department of Psychiatry, Academic Medical Centre
University of Amsterdam & Arq Psychotrauma Expert Group
Diemen, the Netherlands


Bisson, J. I. (2014) Early responding to traumatic events. The British Journal of Psychiatry, 204, 329–330. doi: 10.1192/bjp.bp.113.136077. PubMed Abstract | Publisher Full Text

Brewin, C. R., Fuchkan, N., Huntley, Z., Robertson, M., Thompson, M., Scragg, P., et al. (2010). Outreach and screening following the 2005 London bombings: Usage and outcomes. Psychological Medicine, 40(12), 2049–2057. PubMed Abstract | PubMed Central Full Text | Publisher Full Text

Dückers, M. (2013). Five essential principles of post-disaster psychosocial care: Looking back and forward with Stevan Hobfoll. European Journal of Psychotraumatology, 4, 21914, doi: http://dx.doi.org/10.3402/ejpt.v4i0.21914

Dyb, G., Jensen, T., Glad, K. A., Nygaard, E., & Thoresen, S. (2014). Early outreach to survivors of the shootings in Norway on the 22nd of July 2011. European Journal of Psychotraumatology, 5, 23523, doi: http://dx.doi.org/10.3402/ejpt.v5.23523

Dyb, G., Jensen, T. K., Nygaard, E., Ekeberg, Ø., Diseth, T., Wentzel-Larsen, T., et al. (2013). Post-traumatic stress reactions in survivors of the 2011 massacre on Utøya Island, Norway. British Journal of Psychiatry, 204, s361–367. doi: 10.1192/bjp.bp.113.133157. PubMed Abstract | Publisher Full Text

Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J., et al. (2007). Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry, 70(4), 283–315. doi: 10.1521/psyc.2007.70.4.283. PubMed Abstract | Publisher Full Text

Kassam-Adams, N. (2014). Design, delivery, and evaluation of early interventions for children exposed to acute trauma. European Journal of Psychotraumatology, 5, 22757, doi: http://dx.doi.org/10.3402/ejpt.v5.22757 Publisher Full Text

Langeland, W., & Olff, M. (2008). Psychobiology of posttraumatic stress disorder in pediatric injury patients: A review of the literature. Neuroscience and Biobehavioral Reviews, 32, 161–174. PubMed Abstract | Publisher Full Text

Nordanger, D. Ø., Breivik, K., Haugland, B. S., Lehmann, S., Mæhle, M., Braarud, H. C., et al. (2014). Prior adversities predict posttraumatic stress reactions in adolescents following the Oslo Terror events 2011. European Journal of Psychotraumatology, 5, 23159, doi: http://dx.doi.org/10.3402/ejpt.v5.23159 Publisher Full Text

Refsdal, N. O. (2014). Experiences from coordinating research after the 2011 terrorist attacks in Norway. European Journal of Psychotraumatology, 5, 23215, doi: http://dx.doi.org/10.3402/ejpt.v5.23215 Publisher Full Text

Schultz, J.-H., Langballe, A., & Raundalen, M. (2014). Explaining the unexplainable: Designing a national strategy on classroom communication concerning the 22 July terror attack in Norway. European Journal of Psychotraumatology, 5, 22758, doi: http://dx.doi.org/10.3402/ejpt.v5.22758 Publisher Full Text

Schwarz, E. D., & Kowalski, J. M. (1991). Malignant memories: PTSD in children and adults after a school shooting. Journal of American Academy of Child and Adolescent Psychiatry, 30, 936–944. Publisher Full Text

Scrimin, S., Axia, G., Capello, F., Moscardino, U., Steinberg, A. M., & Pynoos, R. S. (2006). Posttraumatic reactions among injured children and their caregivers 3 months after the terrorist attack in Beslan. Psychiatry Research, 141, 333–336. PubMed Abstract | Publisher Full Text

Suomalainen, L., Haravuori, H., Berg, N., Kiviruusu, O., & Marttunen, M. (2011). A controlled follow-up study of adolescents exposed to a school shooting—Psychological consequences after four months. European Psychiatry, 26, 490–497. PubMed Abstract | Publisher Full Text

Thoresen, S., Aakvaag, H., Wentzel-Larsen, T., Dyb, G., & Hjemdal, O. (2012). The day Norway cried: Proximity and distress in Norwegian citizens following the 22nd July 2011 terrorist attacks in Oslo and on Utøya Island. European Journal of Psychotraumatology, 3, 19709. doi: 10.3402/ejpt.v3i0.19709. Publisher Full Text

Turunen, T., Haravuori, H., Pihlajamäki, J. J., Marttunen, M., & Punamäki, R.-L. (2014). Framework of the outreach after a school shooting and the students perceptions of the provided support. European Journal of Psychotraumatology, 5, 23079, doi: http://dx.doi.org/10.3402/ejpt.v5.23079 Publisher Full Text

Turunen, T., Haravuori, H., Punamäki, R.-L., Suomalainen, L., & Marttunen, M. (2014). The role of attachment in recovery after a school-shooting trauma. European Journal of Psychotraumatology, 5, 22728, doi: http://dx.doi.org/10.3402/ejpt.v5.22728 Publisher Full Text

About The Authors

Grete Dyb
University of Oslo


Miranda Olff
Univ of Amsterdam