Israel-Hamas War: Other Group of Hostages Freed 4:48

(CNN) -- Newly released hostages and detainees can suffer various psychological effects, including anxiety, depression, disorientation, grief, post-traumatic stress and survivor's guilt, upon returning home and after the truce between Israel and Hamas, according to experts.

The truce, which was due to end on Tuesday but was extended for two more days, was the first major diplomatic breakthrough in the conflict.

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During the first four days, Hamas released 69 hostages and Israel released 150 Palestinians, many of whom had been arrested but never charged. Under the terms of the agreement between Israel and Hamas, women and children as young as 18 could be handed over.

"You can predict that the psychological or emotional consequences are going to be severe and you can also predict, from what you know on the ground, that they're going to be very different among the hostages because of the differences in what they experienced when they were taken captive and their ages," said Dr. Spencer Eth, chief of mental health at the Miami VA Healthcare System and a professor at the University of Miami.

"Many of them are not only traumatized by the terror attack and being taken prisoner, but they are also grieving," Eth said, referring among others to Abigail Edan, a 4-year-old Israeli American hostage whose parents were killed by Hamas fighters during the Oct. 7 terror attack.

Noam, 17, and Alma Or, 13, were released Saturday and learned that their mother had been killed on October 7, a family member told CNN. His father is believed to still be held captive in Gaza.


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Nine-year-old Emily Hand, who was released on Saturday, was told that her "second mother," Narkis Hand, her father's ex-wife and mother of Emily's two half-siblings, was murdered on Oct. 7.

"So here we have not only the trauma but also the grief, and that compounds the psychological impact, the very pathological impact, of those events," Eth said.

Eth has not been involved in the care of the hostages, but said those who were released can undergo medical evaluations that could include "very careful" psychological and psychiatric evaluations.

Those evaluations could include looking for signs of traumatic brain injury, post-traumatic stress disorder, or other psychological conditions.

"Just as important as the initial assessment is the need for ongoing monitoring and assistance to see how they evolve," Eth explains.

"Some may feel like they're doing very well, that they're resilient at first, and then they develop severe symptoms later on. And serious symptoms can include depression, especially in people grieving. It's also possible that some people are substance abuse," he explains. "We know that there are a variety of conditions that develop in the aftermath."

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Risk of post-traumatic symptoms

Recovering mentally from such a traumatic event can take years, or even a decade, depending on care. The process tends to take longer for young children and the elderly, explains Ani Kalayjian, founder and president of the international humanitarian nonprofit Meaningful World, an affiliate of the United Nations.

During post-traumatic care and recovery, "I would also like to emphasize the five areas to pay attention to. Physics is very important: vitamins, proper nutrition and exercise to strengthen the muscles," says Kalayjian. "The emotional (numbness, fear, helplessness), the social, in terms of irritability, withdrawal, etc., and the spiritual, such as losing the faith and sense that they once had."

The fifth area is cognitive concerns, such as memory impairment or decreased concentration.

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Walter Busuttil, director of research and training at Combat Stress, the UK's leading charity dedicated to veterans' mental health, says that whenever he has worked with hostages and prisoners of war, they are initially very disoriented when they are released.

"They never knew, for example, whether they were going to be released or not, even though they had been promised. So at first they may seem very happy and, of course, they will be happy that they were released and they will feel a great relief, but some of them will realize, especially adults, that there are other hostages that also need to be released, so they may start to feel guilty, for example," he told CNN's Kim Brunhuber on Saturday.

"The symptoms to look out for are: Are they sleeping well, are they afraid? Are they vigilant, are they anxious, are they eating, what appetite do they have, are they in a good mood, how are they adapting?" he says. "Not everyone will develop any of these symptoms. Many won't develop any symptoms at all."

Some may experience post-traumatic growth, while others may suffer from post-traumatic stress.

PTSD or post-traumatic stress disorder is a mental health disorder that can be suffered by people of any age who experience shocking, frightening, or dangerous events. Symptoms usually appear within three months of the event, but may start later. People with PTSD often have co-occurring disorders, such as depression, substance use, or anxiety.

Signs and symptoms of PTSD in adults may include flashbacks of the traumatic event or recurrent flashbacks, dreams or distressing thoughts, physical signs of stress, avoidance of places, events, or objects that remind you of the event; Being easily startled, having difficulty falling asleep or staying asleep, feeling irritable, or having trouble remembering key aspects of the event.

But children can have extreme reactions to trauma that may not include some of the same symptoms seen in adults, according to the National Institute of Mental Health. In children younger than 6 years, these symptoms may include wetting the bed, forgetting or being unable to speak, being unusually attached to a parent or other adult, or acting out the traumatic event during recess.

"So wellness and mental health professionals are going to have to be aware of the type of games they play, whether they're aggressive or violent, or whether they're very withdrawn," Busuttil explains.

"The youngest children are the most fragile"

Daphna Dollberg, a clinical and developmental psychologist at Tel Aviv-Yaffo Academic College, said many of the Israeli hostages who have been freed may show signs of PTSD, especially children, one as young as 2 years old.

"What we know is that the youngest children are actually the most fragile, and contrary to what we would like to think, young children do remember traumatic events. But because their language is not well developed and they are less prepared to process and communicate to us what they have experienced, they will show their distress through bodily reactions, such as refusing to eat or sleep or becoming physically ill, or they may show their distress through behavioral manifestations and developmental regressions, and sometimes even halts in development," Dollberg told CNN's Laila Harrak on Saturday.

"They're definitely going to be very confused, very scared and on guard and fearful for a long time despite being in a safe place. They can be very hypervigilant, and the most devastating thing is their inability to trust the adults around them, even maybe particularly, their parents, because in their mind, in their childish mind, their parents didn't protect them," he said. "So I suspect we're going to see a lot of signs of PTSD, post-traumatic stress disorder, and we're going to need a lot of time to restore a sense of safety and security and confidence in these young children."

Israel's Ministry of Welfare and Social Affairs issued detailed instructions on how to care for released child hostages.

Israel Defense Forces (IDF) troops have been advised on how to introduce themselves to the children, some of whom have been held in Gaza for more than seven weeks, and how to interact with them after their release but before they are admitted to hospitals.

The guidelines advise that each child or household be assigned a soldier and that soldiers ask permission from children before touching or picking them up.

"Kids will ask questions like, 'Where's Mommy? Where's Dad?' Soldiers should not answer these questions, even if they know the answers. Any question should be answered as follows: 'Honey, I'm sorry, I don't know. My job is to take you to Israel to a safe place, where people you know will be waiting for you and answer all your questions,'" the guidelines say.

The instructions underscore the importance of creating a routine, including rest, balanced meals and moderate physical activity outdoors, during the first week, as well as creating open spaces for dialogue about what the child has experienced.

"Avoid verbally overwhelming the child. Avoid multiple questions and detailed discourse about the events that occurred," the council says. "It's important to use simple words and short sentences. It's important to convey that we're open and able to listen and talk about difficult things."

CNN's Lauren Izso and Alex Stambaugh contributed to this report.

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