Coping with Violence and Disaster
- Trauma: What Is It?
- How children and adolescents respond to trauma
- Assisting the child or adolescent trauma survivor
- Post-Traumatic Stress Disorder
- Treatment of PTSD
- What are researchers learning about trauma in children and adolescents?
Assisting young people avoid or overcome emotional problems in the aftermath of violence or disaster is one of the most challenging roles a parent, teacher, or mental health professional can face. In the aftermath of the terrorist attacks on New York City and Washington, D.C., both children and adults were faced with the emotional impact of extensive damage and losses of life. In addition to 9/11 other acts of terrorism have been felt across the country include the bombing of the Alfred P. Murrah Federal Building in Oklahoma City and the 1999 shootings at Columbine High School in Littleton, Colorado. While these disastrous events became the focus of national attention, they were only a fraction of the many tragic episodes that affect children's lives. Each year many children and adolescents sustain injuries from violence, lose friends or family members, or are adversely affected by witnessing a violent or catastrophic event. Each situation is unique, whether it centers upon a plane crash where many people are killed, automobile accidents involving friends or family members, or natural disasters such as Hurricane Katrina where deaths occur and homes are lost—but these events have similarities as well, and cause similar responses in children. Even in the course of everyday life, exposure to violence in the home or on the streets can lead to emotional impairment.
Studies have revealed that both adults and children who experience catastrophic events exhibit a wide range of responses. Some suffer only worries and bad memories that fade with emotional support and the course of time. Others are more profoundly affected and experience long-term problems. Studies on post-traumatic stress disorder (PTSD) shows that some soldiers, survivors of criminal victimization, torture and other violence, and survivors of natural and man-made catastrophes suffer lasting effects from their experiences. Children who have witnessed violence in their families, schools, or communities are also vulnerable to serious long-term problems. Their emotional responses, including fear, depression, withdrawal or anger, can occur immediately or some time following the tragic event. Youngsters who have experienced a catastrophic event often need support from parents and teachers to avoid long-term emotional harm. Most will recover in a short time, but the few who develop PTSD or other persistent problems need treatment.
TRAUMA: WHAT IS IT?
"Trauma" has both a medical and a psychiatric definition. Medically, "trauma" refers to a serious or critical bodily injury, wound, or shock. This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. Psychiatrically, "trauma" has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, which often results in lasting mental and physical effects.
Psychiatric trauma, or emotional harm, is essentially a normal response to an extreme event. It involves the creation of emotional memories about the distressful event that are stored in structures deep within the brain. In general, it is believed that the more direct the exposure to the traumatic event, the higher the risk for emotional harm. Thus in a school shooting, for example, the student who is injured probably will be most severely affected emotionally; and the student who sees a classmate shot, even killed, is likely to be more emotionally affected than the student who was in another part of the school when the violence occurred. But even second-hand exposure to violence can be traumatic. For this reason, all children and adolescents exposed to violence or a disaster, even if only through graphic media reports, should be watched for signs of emotional distress.
HOW CHILDREN AND ADOLESCENTS RESPOND TO TRAUMA
Responses to trauma may appear immediately following a traumatic event or days and even weeks later. Loss of trust in adults and fear of the event occurring again are responses seen in many children and adolescents who have been exposed to traumatic events. Other responses vary according to age:
For children 5 years of age and younger, typical responses can include a fear of being separated from the parent, crying, whimpering, screaming, immobility and/or aimless motion, trembling, frightened facial expressions and excessive clinging. Parents may also notice children returning to behaviors exhibited at earlier ages (these are called regressive behaviors), such as thumb-sucking, bed wetting, and fear of darkness. Children in this age bracket tend to be strongly affected by the parents' responses to the traumatic event.
Children 6 to 11 years old may exhibit extreme withdrawal, disruptive behavior, and/or inability to pay attention. Regressive behaviors, nightmares, trouble sleeping, irrational fears, irritability, refusal to attend school, outbursts of anger and fighting are also widespread in traumatized children of this age. Also the child may complain of stomachaches or other bodily symptoms that have no medical basis. Schoolwork often suffers. Depression, anxiety, feelings of guilt and emotional numbing or "flatness" are often present as well.
Adolescents 12 to 17 years old may exhibit responses similar to those of adults, including flashbacks, nightmares, emotional numbing, avoidance of any reminders of the traumatic event, depression, substance abuse, problems with peers, and anti-social behavior. Also widespread are withdrawal and isolation, physical complaints, suicidal thoughts, school avoidance, academic decline, sleep disturbances, and confusion. The adolescent may feel extreme guilt over his or her failure to prevent injury or loss of life, and may harbor revenge fantasies that interfere with recovery from the trauma.
Some youngsters are more vulnerable to trauma than others, for reasons researchers don't fully understand. It has been revealed that the impact of a traumatic event is likely to be greatest in the child or adolescent who previously has been the victim of child abuse or some other form of trauma, or who already had a mental health problem. And the youngster who lacks family support is more at risk for a poor recovery.
ASSISTING THE CHILD OR ADOLESCENT TRAUMA SURVIVOR
Early intervention to help children and adolescents who have suffered trauma from violence or a disaster is critical. Parents, teachers and mental health professionals can do a great deal to help these youngsters recover. Help should begin at the scene of the traumatic event.
According to the National Center for Post-Traumatic Stress Disorder of the Department of Veterans Affairs, workers in charge of a disaster scene should:
- Find ways to protect children from further harm and from further exposure to traumatic stimuli. If possible, create a safe haven for them. Protect children from onlookers and the media covering the story.
- When possible, direct children who are able to walk away from the site of violence or destruction, away from severely injured survivors, and away from continuing danger. Kind but firm direction is needed.
- Identify children in acute distress and stay with them until initial stabilization occurs. Acute distress includes panic (marked by trembling, agitation, rambling speech, becoming mute, or erratic behavior) and intense grief (signs include loud crying, rage, or immobility).
- Use a supportive and compassionate verbal or non-verbal exchange (such as a hug, if appropriate) with the child to help him or her feel safe. However brief the exchange, or however temporary, such reassurances are vitally important to children.
After violence or a disaster occurs, the family is the first-line resource for Assistance. Among the things that parents and other caring adults can do are:
- Explain the episode of violence or disaster as well as you are able.
- Encourage the children to express their feelings and listen without passing judgment. Help younger children learn to use words that express their feelings. However, do not force discussion of the traumatic event.
- Let children and adolescents know that it is normal to feel upset following something tragic.
- Allow time for the youngsters to experience and talk about their feelings. At home, however, a gradual return to routine can be reassuring to the child.
- If your children are fearful, reassure them that you love them and will take care of them. Stay together as a family as much as possible.
- If behavior at bedtime is a problem, give the child extra time and encouragement. Let him or her sleep with a light on or in your room for a limited time if necessary.
- Reassure children and adolescents that the traumatic event was not their fault.
- Do not pass judgment on regressive behavior or shame the child with words like "infantile."
- Allow children to cry or be sad. Don't expect them to be fearless or tough.
- Encourage children and adolescents to feel in control. Let them make some decisions about meals, what to wear, etc.
- Take care of your physical and mental needs so that you can take care of the children’s corresponding needs.
When violence or disaster affects a whole school or community, teachers and school officials can play a vital role in the healing process. Some of the things educators can do are:
- If feasible, give yourself a bit of time to come to terms with the event before you attempt to reassure the children. This may not be feasible in the case of a violent episode that occurs at school, but in the case of a natural disaster there will be several days before schools reopen and teachers can take the time to prepare themselves emotionally.
- Don't try to rush back to ordinary school routines too soon. Give the children or adolescents time to talk over the traumatic event and express their feelings about it.
- Respect the preferences of children who do not want to participate in class discussions about the traumatic event. Do not force discussion or repeatedly bring up the catastrophic event; doing so may re-traumatize children.
- Hold in-school sessions with entire classes, with smaller groups of students, or with individual students. These sessions can be very useful in letting students know that their fears and concerns are normal responses. Many counties and school districts have teams that will go into schools to hold such sessions following a disaster or episode of violence. Involve mental health professionals in these activities if possible.
- Offer art and play therapy for young children in school.
- Be aware of cultural differences among the children. In some cultures, for example, it is not suitable to express negative emotions. Also, the child who is hesitant to make eye contact with a teacher may not be depressed, but merely exhibiting behavior appropriate to his or her culture.
- Encourage children to develop coping and analytical skills and age-appropriate methods for managing anxiety.
- Hold meetings for parents to discuss the traumatic event, their children's response to it, and how they and you can help. Involve mental health professionals in these meetings if feasible.
Most children and young adults, if given support such as that described above, will recover almost completely from the fear and anxiety caused by a traumatic experience within a few weeks. However, some children and young adults will need more help perhaps over a longer period of time in order to heal. Grief over the loss of a loved one, teacher, friend, or pet may take months to resolve, and may be reawakened by reminders such as media reports or the anniversary of the death.
In the immediate aftermath of a traumatic event, and in the weeks following, it is imperative to identify the youngsters who are in need of more intensive support and therapy because of profound grief or some other extreme emotion. Children and young adults who may need the help of a mental health professional include those who exhibit avoidance behavior, such as resisting or refusing to go places that remind them of the place where the traumatic event occurred, and emotional numbing, a diminished emotional response or lack of feeling toward the event. Young people who have more typical responses including re-experiencing the trauma, or reliving it in the form of nightmares and disturbing recollections during the day, and hyper arousal, including sleep disturbances and a tendency to be easily startled, may respond well to supportive reassurance from parents and teachers.
POST-TRAUMATIC STRESS DISORDER
As mentioned earlier, some children and young adults will have prolonged problems following a traumatic event. These potentially chronic conditions include depression and prolonged grief. Another serious and potentially long-lasting problem is post-traumatic stress disorder (PTSD). This condition is diagnosed when the following symptoms have been present for longer than one month:
- Re-experiencing the event through play or in trauma-specific nightmares or flashbacks, or distress over events that resemble or symbolize the trauma.
- Routine avoidance of reminders of the event or a general lack of responsiveness (e.g., diminished interests or a sense of having a foreshortened future).
- Increased sleep disturbances, irritability, poor concentration, startle reaction and regressive behavior.
Rates of PTSD identified in child and adult survivors of violence and disasters vary widely. For example, estimates range from 2 percent following a natural disaster (tornado), 28 percent following an episode of terrorism (mass shooting), and 29 percent following a plane crash.
The disorder may arise weeks or months following the traumatic event. PTSD may resolve without treatment, but some form of therapy by a mental health professional is often required in order for healing to occur. Fortunately, it is more typical for traumatized individuals to have some of the symptoms of PTSD than to develop the full-blown disorder.
As noted above, people differ in their vulnerability to PTSD, and the source of this difference is not known in its entirety. Researchers have identified factors that interact to influence vulnerability to developing PTSD. These factors include:
- characteristics of the trauma exposure itself (e.g., proximity to trauma, severity, and duration),
- characteristics of the individual (e.g., prior trauma exposures, family history/prior psychiatric illness, gender. (Women are at greatest risk for many of the most typical assault traumas), and
- Post-trauma factors (e.g., availability of social support, emergence of avoidance/numbing, hyper arousal and re-experiencing symptoms).
Studies have revealed that PTSD clearly alters a number of primary brain mechanisms. Abnormal levels of brain chemicals that affect coping behavior, learning, and memory have been detected among people with the disorder. In addition, recent imaging studies have discovered altered metabolism and blood flow in the brain as well as structural brain changes in people with PTSD.
TREATMENT OF PTSD
People with PTSD are treated with specialized forms of psychotherapy and sometimes with medications or a combination of the two. One of the forms of psychotherapy shown to be effective is cognitive behavioral therapy, or CBT. In CBT, the patient is trained in methods of overcoming anxiety or depression and modifying unwanted behaviors such as avoidance of reminders of the traumatic event. The therapist helps the patient examine and re-examine beliefs that are interfering with healing, such as the belief that the traumatic event will occur again. Children who go through CBT are taught to avoid "catastrophizing." For example, they are reassured those dark clouds do not automatically mean another hurricane, that the reality that just because someone is angry doesn't necessarily signify that another shooting is about to happen, etc. Play therapy and art therapy also can help younger children to remember the traumatic event in safety and express their feelings about it. Other forms of psychotherapy that have been found to help persons with PTSD include group and exposure therapy. A realistic period of time for treatment of PTSD is 6 to 12 weeks with occasional follow-up sessions, but treatment may be longer depending on a patient's individual circumstances. Studies have revealed that support from family and friends can be a vital part of recovery.
There has been a good deal of research on the use of medications for adults with PTSD, as well as studies on the formation of emotionally charged memories and medications that may help block the development of symptoms. Medications have shown to be useful in reducing overwhelming symptoms of arousal (such as sleep disturbances and an exaggerated startle reflex), disturbing thoughts, and avoidance; reducing associated conditions such as depression and panic; and improving impulse control and related behavioral problems. Research is ongoing in the use of medications to treat PTSD in children and young adults.
There is accumulation of empirical data suggesting that trauma/grief-focused psychotherapy and selected pharmacologic interventions can be successful in alleviating PTSD symptoms and in addressing co-occurring depression. However, more research in medication-based treatment is needed.
A mental health professional with particular expertise in the area of child and adolescent trauma is the best individual to help a youngster with PTSD. Organizations on the accompanying resource listing may help you to locate such a specialist in your geographical vicinity.
WHAT ARE RESEARCHERS LEARNING ABOUT TRAUMA IN CHILDREN AND ADOLESCENTS?
Recent research findings include:
- Some studies show that counseling children very soon following a catastrophic event may lessen some of the symptoms of PTSD. A study of trauma/grief-focused psychotherapy among early adolescents exposed to an earthquake found that brief psychotherapy was effective in alleviating PTSD symptoms and preventing the worsening of co-occurring depression.
- Parents' responses to a violent event or disaster strongly weigh in their children's ability to recover. This is predominantly true for mothers of young children. If the mother is depressed or very anxious, she may need to get emotional support or counseling in order to be able to be of aid her child.
- Either being exposed to violence within the home for an extended period of time or exposure to a one-time event like an attack by a dog can cause PTSD in a child.
- Community violence can have a profound effect on teachers as well as students. One study of Head Start teachers who lived through the 1992 Los Angeles riots showed that 7 percent had severe post-traumatic stress symptoms, and 29 percent had moderate symptoms. Children also were acutely affected by the violence and anxiety around them. They were more aggressive and noisy and less likely to be respectful or get along with each other.
- Studies have established that PTSD following exposure to a variety of traumatic events (family violence, child abuse, disasters, and community violence) is often followed by depression. Depression must be treated along with PTSD, and early treatment is best.
- Inner-city children experience the greatest exposure to violence. A study of adolescent boys from inner-city Chicago showed that 68 percent had seen someone beaten up and 22.5 percent had seen someone shot or killed. Youngsters who had been exposed to community violence were more probable to exhibit aggressive behavior or depression within the following year.
Researchers are continuing to conduct studies into the impact of violence and disaster on children and adolescents. For example, one study will follow 6,000 Chicago children from 80 different neighborhoods over a period of several years.
It will examine the emotional, social, and academic effects of exposure to violence. In some of the children, the researchers will look at the role of stress hormones in a child or adolescent's response to traumatic experiences. Another study will deal particularly with the victims of school violence, attempting to find out what places children at risk for victimization at school and what factors protect them.
It is particularly vital to conduct research to discover which individual, family, school and community interventions work best for children and adolescents exposed to violence or disaster, and to find out whether a well-intended but ill-designed intervention could set the youngsters back by keeping the trauma alive in their minds.
Center for Mental Health Services (CMHS)
CMHS is a component of the Substance Abuse and Mental Health Services Administration, U.S. Department of Health and Human Services. The Federal Emergency Management Agency, working with the Center for Mental Health Services' Emergency Services and Disaster Relief Branch (ESDRB), provides funding support for mental health services following a disaster. The Crisis Counseling Assistance and Training Program is implemented at the request of a state or territory when a "Major Disaster" has been declared by the President. Funding for the Crisis Counseling Program (CCP) is not automatic. Funding is provided if the need is beyond the means of state and local providers. Legislative authority is based on the Robert T. Stafford Disaster Assistance Act, Section 416 (Public Law 100-707). There are three components to the CCP program: Immediate Services, Regular Services, and Training and Preparedness. The 60-day Immediate Services Program (ISP) provides services from the date of the incident. The Regular Services Program (RSP) follows the ISP when there is a proven need and provides services for up to 9 months. A week-long training program is completed each year for state mental health authorities to assist in planning for mental health response to disasters. For more information about the CCP program, call the Emergency Services and Disaster Relief Branch, CMHS, at (301) 443-4735.
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