Children’s Responses to Terror and Trauma

Children’s Responses to Terror and Trauma John Sargent, M.D.

Children’s Responses depend upon several variables: • Child’s age and developmental status • Previous experiences of trauma • Family risk and resiliency factors

Children’s Responses depend upon several variables (cont): • Preexisting attachment relationship • Nature of traumatic experience and continuing threat • Nature of community and family support

Influence of Developmental Stage on Child Responses Preschool children • Primary problems are related to separation • Refuse to attend preschool • Sleeping with parent • Whining and clinging behavior with parent

Influence of Developmental Stage on Child Responses (cont.) • Trouble sleeping and nightmares • Reactive aggressiveness • Repressive behaviors; bed wetting and fears

Influence of Developmental Stage on Child Responses (cont.) School Age Children • Attention and concentration problems • Anxiety with associated school avoidance, fears and somatic symptoms • Sleep problems and nightmares

Influence of Developmental Stage on Child Responses (cont.) • Angry outbursts • Depression and withdrawal

Influence of Developmental Stage on Child Responses (cont.) Adolescence • Hypervigilance and intrusive thoughts • Emotional numbing and nightmares • avoidance

Influence of Developmental Stage on Child Responses (cont.) • Peer and family problems • Substance abuse • Overt depression

Influence of Developmental Stage on Child Responses (cont.) Other affective aspects of trauma/terrorism • Humiliation, shame and self-blame • Alienation and demoralization • Chronic anger and irritability • Reexperiencing worsening other symptoms

Unique features of Terroristic Events Effects on Children • Terroristic events have a profound effect upon adults – including parents and teachers • Adult depression may negatively influence children • Adults may underestimate effects upon children, especially for distant events • Parents’ emotional responses very influential in the children’s reactions

Persistent threat worsens children’s exposure and reactions

Repeated media viewing also worsens the effects upon children

PTSD occurs in 30 – 50% of children exposed to terrorist violence

Physical proximity, degree of actual family member involvement and witnessing violence significantly increase risk of developing PTSD

10% of New York City public school students developed PTSD after September 11, 2001. World Trade Center attacks.

Disruption, confusion, chaos, uncertainty of events and surrounding events often worsens the situation

Rumors, excitement, disorder among helpers can be present at the scene or at hospital or care settings

Parental availability and support is highly protective for children (including adolescents)

Helpful interventions: • Establishing order at the site • Ensuring coordinated, cooperative and competent activity among helpers • Ensure parents are with children if possible

Helpful interventions (cont.): • Provide accurate and complete information as soon as available • Ensure appropriate medical care • Support parents and family care givers especially if child is injured and receiving hospital care

Psycho educational supports for families and community networks also are helpful and can lead to rebuilding efforts for the community

School based interventions for children can be very helpful: group discussions, resumption of daily routine and structure, gradual expectation of training and competence

Dimensions of Assessment • Physical well being, differences, acute symptoms and physiologic problems • Developmental capacities, variability, deficiencies and areas of regression • Nature of trauma and its effects

Cognitive capacities including intellectual capacity, specific areas of learning disability and ability to utilize cognitive capacity to understand trauma

Psychiatric symptoms and diagnostic considerations including: • Acute Stress Reaction • PTSD • Depression • Substance Abuse • Eating Disorders • Complex PTSD • Conduct Disorder, etc.

Assessment of Context: family relationships and interaction, community connectedness, community institutions and rituals • Areas of Risk and Resilience: family risk, poverty, social discrepancies, individual strengths, skills and competencies, family and community connection and support.

Other important issues: • Cultural background • Ethnicity • Cultural stories of adversity and survival • Belief systems about trauma recovery • Peer relationships • Current functioning • academic • family • social • community • (especially in relation to expected development)

Stage I: Stabilization • Develop a collaborative team with planned, coordinated responses to traumatic events that are competent, compassionate and caring

Parents will need to be invited to be members of the team with defined and important roles • Swiftly end traumatic events and define all future responses as courageous healing efforts (no matter how disruptive or painful)

Treatment is based upon building a relationship of connection and trust, recognizing the experience of shock, anxiety and arousal in the child and family

Ensuring physical and psychological comfort produces the possibility of focused attention so that information about plans, procedures and treatment can be shared with and gained by child and family

Predictability, clarity, integrity and competence follow the explanations to reinforce trust and collaboration • Be prepared to operate on limited, incomplete and often disguised information, focusing upon what is known and what is required by the situation

Do not expect that a one time large scale debriefing or counseling effort will produce large scale recovery - in fact “Critical Incident Debriefing” often worsens individual psychological responses

Stage II: Restoration • Identify key issues which require attention to reestablish continuity of life for children and their family: • Housing - Living situation - Care-taking relationships • Centrality of Parental Figures (if possible)

Financial resources to ensure family continuity • Building competence through encouragement and active reinforcement of rehabilitation activities

Recognizing grieving as an important activity • Identify appropriate anger and begin discussions of accountability

Resume, whenever possible, developmentally appropriate activities with parental encouragement (which reinforces parenting role)

At this point a comprehensive assessment highlighting individual risk and resilience factors, attention to psychiatric symptoms, and specifics of traumatic experience and emotional reactions is essential and points to appropriate interventions

These interventions further reinforce the relationship between the family and the healing system and further support future collaboration

This leads to increasing clarity about what has changed, been lost and must be grieved for as well as what new competencies have emerged and must be integrated

Build to a recognition of an integrated appreciation of a transformed child and family

Stage III: Recovery • This stage focuses directly upon attention to significant psychiatric symptoms and syndromes

This requires integrated therapeutic responses • Exposure and response prevention directly addresses PTSD symptoms (e.g. Foa’s treatment for rape victims) • Family therapy leads to greater organization, more parental effectiveness and improved social support

Attachment focused psychodynamic psychotherapy enhances mentalization, reduces interpersonal objectification and enhances empathy

Cognitive - behavioral therapy addresses depressed mood, inappropriate attributions of helplessness and shame and excessive focus upon retribution and revenge

Psychopharmacology to improve mood, increase threshold and decrease amplitude of arousal • Behavioral support to decrease avoidance

Enhancing physiologic self-awareness to assist in managing and modulating arousal and psychologic self-awareness to appropriately assess danger

Work toward the consolidation of a coherent narrative of self, family, community experiences of this trauma that becomes a nuanced, textured memory that can be recalled as a whole and reviewed without reproduction of heightened arousal

An orientation toward community and national (if possible) growth through advocacy, truth and reconciliation experiences, memorial and artistic expression

Children’s Responses to Terror and Trauma