Children

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Childrens Responses to Terror and Trauma

• John Sargent, M.D.

2
Childrens Responses depend upon several
variables

• Childs age and developmental status
• Previous experiences of trauma
• Family risk and resiliency factors

3
Childrens Responses depend upon several
variables (cont)

• Preexisting attachment relationship
• Nature of traumatic experience and continuing
  threat
• Nature of community and family support

4
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

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Influence of Developmental Stage on Child
Responses (cont.)

• Trouble sleeping and nightmares
• Reactive aggressiveness
• Repressive behaviors bed wetting and fears

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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

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Influence of Developmental Stage on Child
Responses (cont.)

• Angry outbursts
• Depression and withdrawal

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Influence of Developmental Stage on Child
Responses (cont.)

• Adolescence
• Hypervigilance and intrusive thoughts
• Emotional numbing and nightmares
• avoidance

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Influence of Developmental Stage on Child
Responses (cont.)

• Peer and family problems
• Substance abuse
• Overt depression

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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

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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 childrens reactions

12
Persistent threat worsens childrens exposure and
reactions
13
Repeated media viewing also worsens the effects
upon children
14
PTSD occurs in 30 50 of children exposed to
terrorist violence
15
Physical proximity, degree of actual family
member involvement and witnessing violence
significantly increase risk of developing PTSD
16
10 of New York City public school students
developed PTSD after September 11, 2001. World
Trade Center attacks.
17
Disruption, confusion, chaos, uncertainty of
events and surrounding events often worsens the
situation
18
Rumors, excitement, disorder among helpers can
be present at the scene or at hospital or care
settings
19
Parental availability and support is highly
protective for children (including adolescents)
20
Helpful interventions

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

21
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

22
Psycho educational supports for families and
community networks also are helpful and can lead
to rebuilding efforts for the community
23
School based interventions for children can be
very helpful group discussions, resumption of
daily routine and structure, gradual expectation
of training and competence
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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

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

26
Psychiatric symptoms and diagnostic
considerations including

• Acute Stress Reaction
• PTSD
• Depression
• Substance Abuse
• Eating Disorders
• Complex PTSD
• Conduct Disorder, etc.

27

• 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.

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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)

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Stage I Stabilization

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

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• 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)

31
Treatment is based upon building a relationship
of connection and trust, recognizing the
experience of shock, anxiety and arousal in the
child and family
32
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
33

• 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

34
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
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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)

36

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

37

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

38

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

39
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
40
These interventions further reinforce the
relationship between the family and the healing
system and further support future collaboration
41
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
42
Build to a recognition of an integrated
appreciation of a transformed child and family
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Stage III Recovery

• This stage focuses directly upon attention to
  significant psychiatric symptoms and syndromes

44

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

45

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

46

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

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

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

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• 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

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

• Competence and connection are antidepressants
• Information, predictability, intellectual mastery
  and mentalization manage anxiety, splitting and
  impulsivity

52

• Recognition of what needs to be protected now and
  of the value of new skills promote consolidation
  of a transformed self

53

• Therapist is vulnerable to burn out, vicarious
  traumatization and personal experience of
  vicitimhood

54

• Therapists will need to identify the value and
  meaning of their work while they integrate their
  awareness of tragic events and of change and
  growth that reinforces hope