Childhood Reactions to Terrorism-Induced Trauma by Wanda P. Fremont, M.D. The unpredictable, indefinite threat of terrorist events, the profound effect on adults and communities, and the effect of extensive terrorist-related media coverage can contribute to a continuous state of stress and anxiety in children. Current treatment strategies are discussed as well as direction for further research.
Terrorist threats and attacks have become more frequent throughout the world over the past several years. There is increasing concern about the effects of terrorism on children and their families. Health care providers, parents and teachers are struggling to help youngsters cope with heightened anxiety and fear.
Recently, more research has been conducted to examine the effects of this exposure. The extent of this research, especially data that help differentiate reactions to terror from those associated with other types of violence, is scant. In order to develop a proactive and strategic response to these reactions, it is important for clinicians and policy-makers to understand the psychological effects of terrorism on children.
Terrorism and Its Effect on Children Defined
The goal of terrorism is to use violence or the threat of violence to inflict psychological fear and intimidation at any time, during periods of peace or conflict. Terrorist activities result in severe trauma and cause visible damage, which creates strong emotional responses. Unlike family or community violence, or trauma resulting from war, terrorist activities may occur suddenly without any forewarning, and the threat persists indefinitely. Terrorist threats and actions are enhanced by media coverage, which exacerbate underlying anxieties.
Studies on the subject of terrorism and children emerged in the aftermath of recent terrorist events. These include the Sept. 11, 2001, terrorist attacks, the 1995 bombing of the Alfred P. Murrah Federal Building in Oklahoma City, the SCUD (surface-to-surface missile system) attacks and terrorist activities in Israel, and state terrorism in Guatemala between 1981 and 1983.
Childhood Reactions to Terrorism-Induced Trauma
Many of the effects of terrorism-induced trauma on children are similar to the effects of man-made and natural disaster. Therefore it is important for clinicians to understand children's reactions to trauma and, in addition, to acquire knowledge about the unique effects of terrorist-induced trauma on children.
Children vary in their reactions to traumatic events (Yehuda et al., 1998). Some suffer from fears and memories immediately after the event, which dissipate with time and emotional support. Other children are more severely affected by trauma and experience long-term problems. Children's responses include acute stress disorder, posttraumatic stress disorder, anxiety, depression, sleep disturbances, separation difficulties, and regressive and behavioral problems. The DSM-IV-TR identifies two types of stress disorders, according to their temporal manifestations of reactions to trauma. Acute stress disorder is the most common psychiatric disorder following a traumatic event. Children's emotional reactions and symptoms occur immediately after the trauma. Symptoms of PTSD develop later. Children and adolescents suffering from acute stress disorder or PTSD may re-experience the trauma by having nightmares or recurring flashbacks of the trauma. They may avoid situations that arouse recollections of the trauma and manifest symptoms of numbness or withdrawal. Children may also suffer from symptoms of increased arousal including hypervigilance, sleep difficulties, irritability, difficulty concentrating and outbursts of anger. Each child will react differently depending on their sensitivity and temperament and whether they tend to internalize or externalize their experiences and emotions. Play and study may be affected in addition to patterns of sleep or eating.
Children may develop comorbid disorders in addition to acute stress disorder and PTSD, including anxiety disorders, depression and substance abuse-related disorders. Children may present with partial or variable symptoms of these disorders (Macksoud et al., 1993).
Risk and Protective Factors for Children and Adolescents
Childhood reactions to trauma and terrorist events depend on several risk and protective factors. These include factors related to individual, family, and community strengths and vulnerabilities in addition to variables related to the history and terrorist event itself.
One of the most important factors that determine children's response to violent events and their ability to cope is the influence of their parents' responses to the trauma. Terrorist incidents affect adults profoundly, and they may not be able to provide the support and reassurance needed to help avoid potential long-term emotional harm to their children. The importance of parental involvement in mediating stress reactions in children has been studied in families exposed to terrorist attacks (Bat-Zion and Levy-Shiff, 1993; Laor et al., 2001). Increased levels of stress and morbidity were noted in children whose parents responded to traumatic events with negative emotions including depression and poor psychological functioning. Positive coping responses in children were associated with parents who responded with positive emotional reactions to trauma (Bat-Zion and Levy-Shiff, 1993). Children with adequate family cohesion manifest less stress in reaction to trauma and are better able to recover from the initial impact of the trauma (Laor et al., 2001). Family protective factors that have been shown to buffer stress for children and increase resiliency include:
Children's responses vary in accordance to their level of exposure to the terrorist activities, either directly or indirectly. The degree of exposure to terrorist actions is related to the prevalence of PTSD. The more severe the traumatic event, the greater the risk of developing posttraumatic symptoms (Bat-Zion and Levy-Shiff, 1993; Pynoos et al., 1987; Thabet et al., 2002). Children who directly experience loss are more symptomatic (Bat-Zion and Levy-Shiff, 1993; Pfefferbaum et al., 1999). Physical injury, or witnessing death and physical injury of others, is associated with higher rates of PTSD and comorbid depression and anxiety. The degree of personal loss (i.e., the child's relationship to the victim) has also been correlated with the number of posttraumatic stress symptoms in less exposed children. Knowing an injured or deceased person increased the risk of symptom development (Nader et al., 1990). In addition to the level of trauma, the duration of exposure to violence predicts risk for development of psychiatric problems in children (Goldstein et al., 1997; Pynoos and Nader, 1989).
The differential response to trauma depends, in part, on the child's age and level of psychological maturity (Osofsky, 1995). Children age 5 and under may exhibit regressive behaviors such as bed-wetting, thumb-sucking or fear of the dark. They may have increased difficulties separating from their parents. Repetitive play may occur in which themes or aspects of the trauma are expressed. Their dreams may be frightening, but without any recognizable content. School-age children (ages 6 to 11) may have attention problems and schoolwork may suffer. Signs of anxiety include school avoidance, somatic complaints, irrational fears, sleep problems, nightmares, irritability and angry outbursts. They may appear to be depressed and more withdrawn. Adolescent (ages 12 to 18) responses are more similar to adults and include intrusive thoughts, hypervigilance, emotional numbing, nightmares, sleep disturbances and avoidance. They are at increased risk for problems with substance abuse, peer problems and depression. Trauma is often associated with intense feelings of humiliation, self-blame, shame and guilt, which result from the sense of powerlessness and may lead to a sense of alienation and avoidance.
Predisposing risk factors may cause some children to be at greater risk to develop symptoms of anxiety and depression. These include past exposure to traumatic events during childhood, childhood conduct problems and childhood anxiety, as well as antisocial behavior or a family history of psychiatric disorders (Applied Research and Consulting, LLC et al., 2002; Breslau and Davis, 1992).
Responses of community members in populations exposed to terrorism have an important influence on children's coping skills. Children's resiliency to traumatic events is influenced by the degree of social support and positive community influences (Garbarino et al., 1992). Community ideology, beliefs and value systems contribute to resiliency by giving meaning to dangerous events, allowing children to identify with cultural values, and enabling children and adults to function under extreme conditions (Melville and Lykes, 1992).
Media exposure of disaster events has been correlated with posttraumatic stress symptoms in children (Applied Research and Consulting, LLC et al., 2002; Pfefferbaum et al., 2000, 1999; Phillips et al., 2004; Saylor et al., 2003; Schuster et al., 2001; Terr et al., 1999). Children who experience personal losses are at greater risk to watch significantly more terrorist-related television coverage than those children without direct losses. This further exacerbates the traumatic experience.
Media coverage of the Sept. 11 terrorist attacks was extensive, and repeated coverage of the graphic images of planes striking the World Trade Center caused considerable concern about the added emotional effects of viewing the traumatic events. Several studies have shown that the prevalence of stress-related symptoms was higher in children who spent more time watching coverage of the events on television or the Internet or reading about them in the newspapers (Saylor et al., 2003; Schuster et al., 2001).
Clinical Interventions and Treatment
The effectiveness and comparative advantages of specific interventions and treatment modalities for children exposed to terrorism has not been extensively examined. Only recently have researchers developed rigorously designed studies to examine the effectiveness of treatments in children exposed to non-terrorism-induced trauma (e.g., single-incident traumas, natural disasters, sexual abuse, community violence and war-induced trauma). Because children exposed to terrorist activities often manifest similar symptoms to children who have experienced other types of trauma, the results of literature on community, school-based, individual, and family interventions and treatments for children exposed to trauma may have significant implications for children exposed to terrorism.
The application of trauma-focused interventions addresses several protective and risk factors. The interventions emphasize the importance of parents and community reactions. Providing assistance to parents and caregivers, and including them in treatment is considered a crucial component of treatment. Psychoeducation, cognitive restructuring, exposure and coping skills management are emphasized. The importance of the effects of distant trauma and media coverage is taken into consideration.
Essential intervention strategies to community-wide acts of terrorism include early community-based intervention; clinical needs assessment to identify children at risk; multimodel, trauma-loss-focused treatment programs; and program evaluation of treatment efficacy (Gurwitch et al., 2002). Early community-based interventions focus on safety and protection, emotional support by parents and caregivers in the community, and stress-related symptom reduction. Although there is no consensus on the most effective method of assessment, numerous structured interviews and self-reports are available (American Academy of Child & Adolescent Psychiatry, 1998; Cohen et al., 2000). Community-wide screening (conducted in schools, primary care settings or neighborhood centers) is necessary to identify children at risk and children in need of acute, trauma-related service. An important component of the screening process is differentiating normal (developmentally appropriate) reactions to trauma from abnormal reactions. After children in need of treatment have been identified, appropriate triage and referral should be made to specialized treatment programs based on the specific needs of the child, family or community.
Family therapy, adult therapy, group therapy, and school and community interventions have been used to treat traumatized children and families, help them with coping skills, and address issues related to trauma and loss. Psychoeducational group meetings (parent or community meetings) reduce symptoms of individual, family, and community fear and arousal levels (Nader, 1997). Several manualized treatment programs for use following community traumatic events, including acts of terrorism, have been developed and distributed internationally (Gurwitch and Messenbaugh, 2001; La Greca et al., 2001). These intervention programs and materials include active involvement of parents, caregivers, health care providers, community leaders and educators. They present educational materials on basic safety skills, psychological stress responses and treatment exercises to address symptoms and behavioral difficulties associated with trauma and loss. The preliminary results of the interventions and manuals developed to aid children after terrorist attacks are promising. However, outcome data have not been examined, and further research is needed to evaluate their effectiveness.
Children and families who manifest significant psychiatric impairment and dysfunction are in need of more intensive mental health interventions treatment. Cognitive-behavioral therapy (CBT) has been the most rigorously studied treatment for traumatized children (March et al., 1998). Cognitive restructuring (reprocessing the traumatic event and identifying traumatic triggers), relaxation training, anger management training, teaching of proactive coping skills and grief management are important methods to treat PTSD after disasters. However, the effectiveness of CBT in treating children exposed to chronic trauma, comorbid disasters, past history of trauma exposure and serious family dysfunction has not been studied.
Minimal data are available on the effectiveness of pharmacotherapy to treat symptoms of PTSD in children. Selective serotonin reuptake inhibitors have been shown to have therapeutic effects on symptoms of depression and anxiety disorders in children (Walkup et al., 2001). Because symptoms of anxiety and depression are common symptoms in children following trauma, treatment with SSRIs has been considered as a treatment option.
The Need for an Effective Public Health Approach
The continuing frequency of terrorist events around the world and their impact on children and families underscore the urgency of providing an effective public health approach for the needs of children and their families. Educating and preparing mental health organizations and providers is essential for children who need care in the aftermath of terrorist activities. Collaboration between mental health organizations, both nationally and internationally, has already been initiated and is likely to continue to grow and develop.
The federal disaster mental health approach in the United States has developed over several decades. Initially based on experiences with natural disasters, many modifications to the federal approach have recently been included to address the unique effects of violent acts of terrorism. These include more effective crisis intervention methods and better triage and referral services. Continued difficulties include identifying the extent of services needed, the scope and depth of personnel and funding necessary to provide services, and the anticipated duration of treatment. Obtaining adequate funding and resources by federal mental health agencies will continue to be a significant challenge in the future.
Dr. Fremont is assistant professor of child and adolescent psychiatry and director of the Child and Adolescent Psychiatry Residency Training Program at State University of New York (SUNY) Upstate Medical University. She is also a faculty member in the departments of pediatrics and family medicine at SUNY Upstate Medical University.
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