The primary goal of a terrorist act is not to kill or cause physical harm, but rather to instill a state of terror in a much larger group of secondary victims. The psychological and emotional impact is the predominant morbidity of a terrorist event. Too often, plans to respond to acts of terrorism either ignore or minimize the terror part of terrorism. Plans only begin to address the psychological aspects as part of the aftermath or recovery services, instead of as an integral part of the planning and service delivery during a crisis event. Ignoring the emotional impact of terrorist events only heightens the sense of terror in the affected population - thereby potentiating the impact of terrorism, not minimizing it.
Although society should make every reasonable attempt to prevent terrorism, the reality is that complete elimination of all vulnerability can never be achieved. Children can be expected to be among both the direct and the secondary psychological victims of domestic terrorism events. Consequently, pediatricians and other child health care providers must play a role in the planning and delivery of traditional medical services in order to minimize the physical health threats to children. However, we must also play a central role in addressing the psychological component - the terror in terrorism.
In order to be effective crisis mental health providers, we need to acquire the necessary clinical acumen to identify the psychological symptoms that may result from an act of terrorism. Pediatricians should be able to perform timely and effective triage and to initiate brief supportive interventions, and make appropriate referrals as indicated. Often, neither the children nor the parents of those most in need of supportive services in the aftermath of a terrorist event may recognize their symptoms as being psychological in nature.
In the context of a terrorist event, somatization may be common. Providers must help children and their families understand and begin to address the underlying psychological origin of the physical complaints. Pediatricians can identify parents who are having difficulties themselves. Children's adjustment depends in large part on the ability of their parents to handle difficult events. By identifying and directing parents to supportive and counseling services, adjustment and recovery of the entire family is improved.
In some situations, children and their families may be aware of their emotional and psychological needs, but they may be unaware of the availability of supportive or counseling services, unsure how to access them, or be reluctant to seek mental health services because of the stigma associated with mental illness. Pediatricians can help minimize all of these barriers to appropriate care.
This article outlines the symptoms of adjustment reactions to terrorism so pediatricians can identify potential symptoms in their patients. Known risk factors that place children at increased risk of adjustment difficulties are reviewed to help clinicians anticipate which children are at greater risk and to identify potential opportunities for preventive interventions. Pediatricians have a unique opportunity to help parents and other caregivers communicate with children in ways that allow them to understand better and to recover from traumatic events. Toward this end, practical advice for parents is reviewed to support children in settings of national crisis.
CHILDREN'S REACTIONSTO TERRORIST EVENTS
Our knowledge about how children respond to acts of terrorism is based in large part on clinical experience and limited research involving children in the setting of both natural and manmade disasters.1,2 Disasters involving human intent to cause harm are known to cause more psychological problems than natural disasters. While there has been limited research conducted on adjustment reactions of children in the setting of terrorism, findings that include the emerging results of studies involving children and adolescents after the terrorist attacks of September 1 1, 2001, have supported the conclusions based on earlier studies of children and disasters.
How children respond to a terrorist event depends in large part on their cognitive, social, and emotional developmental level, their prior experiences and preexisting mental health and coping skills, and the resources they have within their families and communities to support them in times of stress. A wide range of symptoms may indicate a child is having difficulty adjusting to a terrorist event. Children may demonstrate fears, either fears specific to the crisis event, such as a fear of entering tall buildings after the attacks on the Word Trade Center, or more general anxiety or fears, such as a fear of the dark or of being left alone. Separation anxiety may lead to school avoidance; difficulty concentrating may result in academic problems. Sleep problems, such as nightmares, trauma-specific dreams, or difficulty falling asleep, also may be present.
In situations of stress, children may regress developmentally and adopt behavior more typical of a younger child. Children who recently mastered toileting may develop secondary enuresis; preschoolers who were confident and independent in separating from parents at daycare may cling more and develop separation problems. Social skills may also regress - children and adolescents may become less cooperative, more self-centered, or argumentative. Pediatricians need to warn parents and other adults who work with children, such as teachers, that this may be a sign children are having difficulty coping; it is not a time to accuse children of being selfish or uncaring. Paradoxically, it is a time to show children more concern and to provide more support. Children may develop stress-related physical symptoms, such as headaches or abdominal pain. Depression and a pessimism about the future are additional symptoms of adjustment difficulties. Older children and adolescents also may initiate or increase substance abuse.
Posttrau m at i e Stress Disorder
Some children likely will respond to an act of terrorism by developing posttraumatic stress disorder (PTSD). Six months after the terrorist attacks on the Word Trade Center, approximately 11% of students attending grades 4 to 12 in New York City public schools self-reported symptoms consistent with the diagnosis of PTSD; at least two thirds of these children reported they had not sought any counseling services from mental health providers for their symptoms.3 Symptoms of PTSD include re-experiencing the traumatic event, avoiding reminders of the event, and experiencing increased arousal. To qualify for the clinical diagnosis, symptoms must be present for at least 1 month. Re-experiencing may encompass intrusive images, traumatic dreams, a sense that the event is somehow recurring, or intense distress at physical or psychological reminders of the event.
Because of the distress associated with reminders, children with PTSD actively avoid reminders of the event, including associated thoughts or feelings, and they may experience psychological numbing and reduced interest in typical activities. This avoidance, which is one of the core symptoms of PTSD, is a major reason why affected individuals typically avoid seeking professional assistance and why active outreach after a terrorist event is necessary. The increased arousal may present as an exaggerated startle response or hypervigiliance and result in difficulty concentrating or sleeping, or general irritability or anger.
Not all children are equally at risk of developing PTSD after exposure to a terrorist attack. Those children who were direct victims or have a close family member or friend who was a victim of the attack are at much higher risk, especially if injury or death was involved or if the children perceive (whether or not accurately) their life had been in jeopardy during the event.
Posttraumatic stress disorder is also more likely to occur among children who witnessed the event directly, especially if this involved exposure to horrific scenes. Viewing of graphic media coverage of terrorist events also is associated with increased adjustment difficulties. Children with a history of prior traumatic experiences or antecedent psychopathology are at greater risk of developing PTSD and other adjustment difficulties as well. Those who experience separation from parents, a major disruption of routine (such as through required relocation of school or home), or loss of home or personal property are also more vulnerable.
Children depend on their parents not only to be safe, but also to feel safe and secure. Parents who are able to cope well with the events and to provide a supportive family environment are able to decrease the risk of adjustment difficulties in their children. Similarly, a supportive community network can be a protective factor.
Much of the mental health literature regarding children's responses to acts of terrorism focuses on PTSD and traumarelated symptoms. For children who were direct victims or witnesses, or family members or close friends of such victims, the risk of PTSD is significant. Half of the children surveyed in New York City public schools whose parents died in the World Trade Center attack self-reported symptoms consistent with PTSD 6 months later, while one of four children who had a parent or sibling who escaped from the World Trade Center also had probable PTSD by self-report.3 But PTSD is not the only difficulty that children may experience as a result of terrorism.
When a terrorist event results in deaths, the predominant adjustment problems for children whose family member or friend died may be bereavement-related, especially if the children did not witness the death or the event. Traumatic grief may be seen in those children dealing both with personal loss and traumarelated symptoms. For some children who were not directly impacted, a sense of sadness for the loss of others, increased concerns about safety of self and significant others, or anxiety may be the main reactions.
Crisis events and other unexpected losses can challenge our assumptive world. Most of the time we function under certain assumptions: we (and others we care about) can go to work or school and return safe and unharmed; we (and others we care about) can travel by car, train, boat, or plane, and arrive at the intended destination safely; we (and those we care about) are and will remain safe and healthy. These assumptions allow us to continue with our day-to-day lives, despite all of the inherent risks, without feeling overwhelmed. But an act of terrorism, as with other tragedies, confronts us with the harsh reality that these assumptions are not completely accurate. After a crisis event, individuals often grieve the loss of their assumptive world. Children, therefore, may experience a range of adjustment reactions after a terrorist event Just because the vast majority of children do not demonstrate PTSD or even trauma-related symptoms does not mean most children are unaffected. At some level, we are all impacted by a terrorist event.
Most Adjustment Problems Are Not Reported to Pediatricians
Parents and teachers often underestimate how much children have been impacted by a terrorist event, especially when it is related to internalizing symptoms that are not associated with obvious behavioral changes. Children may not share their symptoms with parents or teachers because they view the symptoms as abnormal or inappropriate, or because they are attempting to protect the adults who may be visibly upset by the terrorist event themselves.
After the events of September 11, 200 1 , many adults were reluctant to share their personal feelings and reactions with children, in large part because the adults were afraid they themselves might become overwhelmed if they allowed themselves to express their feelings. Children are more likely to be able to learn how to cope with their own negative feelings if they have the opportunity to see competent adults express personal concerns and model effective coping techniques. In fact, after a terrorist event, many adults may be so overwhelmed by their own personal reactions that they are slow to appreciate that children are impacted as well. Pediatricians need to support parents and school personnel so they can identify and address the needs of children in times of crisis.
In some situations, parents may be aware of symptoms of adjustment difficulties in their children but fail to report them to their pediatrician because they may not think the pediatrician is interested in hearing about them, or because they assume such symptoms are "normal reactions to an abnormal event" and therefore do not warrant medical attention. The stigma associated with mental illness often generalizes to the receipt of even supportive mental health services and does not disappear even in times of national crisis.
Pediatricians must be able to help families and communities appreciate that the central issue is not whether children need counseling or support, but whether they might benefit from it. Given the large number of children who would likely benefit from supportive services at the time of a terrorist event (and other crisis situation), pediatricians should advocate for services to be offered to children and families at community sites, such as schools. Amidst a crisis, pediatricians can play a critical role in advocating for, consulting to, or actively participating in a school crisis response team.4,6
Relation of Responses to Crisis and Other Life Events
A terrorist event or other crisis situation often uncovers feelings related to another ongoing or past crisis that was not fully resolved. At times of stress, children may disclose these personal crises, many of which, although not associated at all with the current event, may be the predominant concern for the particular child. Therefore, pediatricians should be prepared for the surfacing of both related and unrelated concerns and issues at the time of a terrorist event. If unanticipated, this may overwhelm crisis support services given the high prevalence of traumatic events in the lives of children. For example, 64% of children in grades 4 through 12 in the New York City public schools reported they had been exposed to one or more traumatic events prior to September 11, 2001: 39% had seen someone killed or seriously injured, 29% had experienced the violent or accidental death of a close friend, and 27% had experienced the violent or accidental death of a family member.3
TALKING WITH CHILDREN ABOUT TERRORIST EVENTS
In the setting of a terrorist event, the short-term goals are to help children understand what has occurred; to identify, express, and understand their feelings; to start to regain a sense of personal control; and to resume developmentallyappropriate activities. Children who are also dealing with deaths of family members, peers, or friends also may benefit from additional bereavement support.7 To achieve these goals, pediatricians can help parents identify and address their children's reactions and coping skills. Pediatricians can serve a critical function in helping parents in this task by providing practical advice to parents and other helping adults, such as school staff.
Parents, teachers, and other adults may be reluctant to begin a discussion about a recent terrorist event with children for fear that they won't know how to respond. What children often need most is someone they trust to listen to their questions, accept their feelings, and be there for them. Adults also may be concerned that such conversations will upset children. Although children may appear upset during such conversations, it is important to remember that it is not the conversation that is causing the distress, but the terrorist event. Talking about the event provides children an opportunity to indicate what is bothering them, which is the first step to obtaining supportive services that ultimately can help them cope with their feelings.
Helping Children Understand
Parents and other adults, such as teachers, should inform children about a terrorist event as soon as information becomes available. Even young children can sense when a serious event has occurred and will become concerned even if they are told little about what has happened; often they imagine something even worse than the actual occurrence. Silence is rarely comforting to children in crisis situations and implies that a serious event is too horrible to even discuss. In addition, it communicates to children that it is inappropriate to discuss such events and their associated feelings, and renders it unlikely that children will ever feel comfortable discussing their concerns related to the event, even with trusted adults. It is important to make a conscious effort to create environments in children's homes, in our practices, in schools, and in other community sites where it is safe to ask questions, to learn what has and is happening, to understand the events, and to make sense of the events together.
Children, just as adults, deal better with a situation when they feel they understand it. The amount of information to provide to children depends in part on their age, their personalities, and their typical coping styles. Older children and adolescents generally benefit from more information. But regardless of the children's age, it is best to start by stating the basic facts in simple, direct, and clear terms. Next ask the children what questions they have and what further information they would like. If there is a possibility they may have learned of the event from another source (eg, if the event occurred earlier in the day), it is often best to start by asking children what they already know. As they explain what they understand, misconceptions and misunderstandings may become apparent and can be corrected. Pay particular attention to misconceptions that might result in unnecessary fears.
Limiting Television Viewing
While it is important to inform children so they can feel they understand it, it is also important to avoid sharing graphic details with them. Television and other media often provide detailed and unnecessarily graphic information that is not helpful to children. Parents should strongly consider limiting the amount of television viewing of young children around the time of a terrorist event. If older children and adolescents watch television coverage of terrorism, adults should watch with them and help them understand and process the information and associated feelings. When possible, adults should consider videotaping television shows rather than allowing their children to watch them live. Parents can then preview the material and decide whether to share it with their children. Pediatricians should also work with schools to establish appropriate guidelines for use of television and other media in the setting of crisis events; in particular, live television viewing in classrooms of terrorist events should be discouraged actively.
Assure Children of Their Safety
In the aftermath of a terrorist attack, children may inquire if another event could occur. This question resonates strongly with adults who share the same concern, but adults should realize that when children ask this question in the setting of a recent terrorist attack, often the underlying question they are asking is whether they should feel safe. While terrorist acts serve as a harsh reminder that we are in fact never completely safe, following a terrorist attack is a time to reassure children, to the extent that you honestly can do so, they should feel safe in their school, home, and community. Adults should take this opportunity to reassure children of all the steps that they and other adults in the community and government are taking to keep them safe. Even if adults feel that they have given all possible reassurances, it is still important to ask children explicitly about their concerns. This may uncover unwarranted concerns based on limited information or immature comprehension as well as accurate and appropriate concerns to serve as the starting point for a dialogue regarding coping with troubling feelings.
Addressing Issues of Responsibility
Just as adults, children may wonder what could have been done to prevent a terrorist attack. If they know someone who died or was seriously injured in the attack, they may feel particularly guilty, even if there is no logical reason to believe they had any responsibility and it is clear there is nothing they could have done to prevent or lessen the tragedy. Such guilt is associated with more severe and prolonged PTSD reactions. Children obviously may be reluctant to share such concerns with others, so adults should carefully watch for signs of possible guilt and consider reassuring children of their complete lack of responsibility.
Children also may wonder who might be at fault and express anger at those they perceive to be responsible for committing the terrorism or for failing to prevent the attack, including their parents and other adults they depend on to protect them. If trusted adults are able to share their own feelings, such as fear, sadness, or empathy, children also may be more likely to express other feelings.
Helping Children Who Appear Disinterested
Older children and adolescents who are used to turning to their peers to discuss issues of importance may initially be resistant to attempts by adults to discuss recent terrorist events. It is generally not appropriate to force such conversations. Instead, parents should extend the invitation on multiple occasions but wait for the invitation to be accepted. In the interim, parents can provide a physical presence and an emotionally supportive environment. They can also draw on their knowledge of what has helped their children cope with difficult events in the past since what helped children before may be helpful again.
Although some children may appear highly impacted by a terrorist attack in their community or elsewhere, other children may appear to be disinterested and even irritated by continued discussion or attention to the event. Children generally are concerned most about what impacts them directly, so they may not be affected immediately by events they do not perceive as directly relevant to their lives. Pediatricians should warn parents that children and adolescents may think mainly of themselves at times of crisis, at least initially. Adults who do not understand this may interpret children's selfcenteredness as a sign of being selfish or uncaring. Once children feel they have had their needs met, they are more capable of thinking about and addressing the needs of others.
Children also may appear disinterested because they do not know or understand what has occurred, do not appreciate the implications of the event, are not comfortable expressing their feelings or are too overwhelmed by their feelings, or conclude that there is little to gain by discussing the event or their reactions. When talking with children after a terrorist event, adults should assist them in figuring out how they can be helpful. Rather than focusing on what could have been done to prevent a terrorist attack, adults can help children figure out what they can do to assist others, including friends, family members, other community members, or ultimately those most impacted by the event.
Dealing With Delayed and Anniversary Reactions
Pediatricians can help families and their communities appreciate the timing of reactions to terrorist events. While many children demonstrate clear reactions immediately after a terrorist attack, it is not uncommon for PTSD to become evident several years later. In addition, at the anniversary of a crisis event, children may experience an increase or resurfacing of some of the feelings and reactions they initially experienced around the time of the terrorist event. Pediatricians can help families, schools, and communities anticipate anniversary reactions and provide concrete advice on how to plan to make participation in commemorative events meaningful and supportive for children.8
We cannot prevent terrorism, nor can we fully "immunize" children against stress associated with crisis situations. We can, however, identify and address children's underlying vulnerabilities that place them at increased risk of adjustment difficulties in response to a terrorist attack; help them enhance coping skills they can draw upon in crisis situations; promote the creation of an infrastructure to support children and their families optimally in times of crisis; and ensure early identification, triage, and intervention for adjustment reactions in times of crisis. Pediatricians have a long-standing history of supporting children and their families at their times of greatest need - delivering difficult diagnoses, supporting children through painful treatments and hospitalization, and assisting children and their families with a wide range of other life crises, such as death of the child, family member, or peer. Supporting children in times of terrorism is therefore a logical extension of pediatrie care and well suited to our ongoing relationship with children and their families.
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