Psychiatric Annals

CME Article 

Risk and Resilience in Children in the Context of Mass Trauma

Grace L. Whaley, LMSW; Vandana Varma, MD; Erin M. Hawks, PhD; Robyn Cowperthwaite, MD; Lenore Arlee, LCSW; Betty Pfefferbaum, MD, JD

Abstract

This article explores the extant literature on outcomes of mass trauma in children as well as factors that predict risk and interventions used to enhance resilience and promote recovery. Many children display acute stress reactions after a mass trauma and some will develop chronic symptoms, but most will recover or demonstrate resilience. Children's reactions include posttraumatic stress symptoms, depression, anxiety, and behavior problems. Various factors predict resilience and vulnerability in children after a mass trauma. These include preexisting factors such as the child's demographics, personality, and previous trauma exposure. The type and degree of exposure to the trauma influences outcomes, with direct exposure or loss of loved ones contributing to worse outcomes. The postdisaster environment, including disaster-related disruption and family and social factors, may hinder or enhance a child's recovery. The aforementioned factors may be used to inform assessment of risk and resilience in public and mental health settings in children after a mass trauma. Effective interventions vary based on the child's exposure and symptomology, timing of intervention in relation to the trauma, and the resources available for service provision. [Psychiatr Ann. 2020;50(9):387–392.]

Abstract

This article explores the extant literature on outcomes of mass trauma in children as well as factors that predict risk and interventions used to enhance resilience and promote recovery. Many children display acute stress reactions after a mass trauma and some will develop chronic symptoms, but most will recover or demonstrate resilience. Children's reactions include posttraumatic stress symptoms, depression, anxiety, and behavior problems. Various factors predict resilience and vulnerability in children after a mass trauma. These include preexisting factors such as the child's demographics, personality, and previous trauma exposure. The type and degree of exposure to the trauma influences outcomes, with direct exposure or loss of loved ones contributing to worse outcomes. The postdisaster environment, including disaster-related disruption and family and social factors, may hinder or enhance a child's recovery. The aforementioned factors may be used to inform assessment of risk and resilience in public and mental health settings in children after a mass trauma. Effective interventions vary based on the child's exposure and symptomology, timing of intervention in relation to the trauma, and the resources available for service provision. [Psychiatr Ann. 2020;50(9):387–392.]

Disasters and terrorism are becoming increasingly common and can wreak havoc on people, families, and entire communities. Children are particularly vulnerable to many aspects of mass trauma, and they rely on a supportive environment for recovery. This article explores adaptive and maladaptive responses to mass trauma and factors that influence a child's resilience, such as demographics, personality, previous trauma exposure, proximity and type of exposure to the current trauma, cascading effects of the event, and interpersonal relationships. Although many children recover from the stress associated with mass trauma without formal intervention, the extensive devastation calls for mental health professionals to consider the unique needs of children, provide families with psychoeducation and guidance, and intervene clinically as necessary based on the child's exposure, reactions, and resources.

Outcomes After a Mass Trauma

Patterns of Adaptation and Maladaptation

Four trajectories of trauma outcomes have been identified: resilience (a stable, low level of distress and symptoms); recovery (moderate to severe disruption in functioning initially that gradually decreases to mild symptoms that persist over time); chronicity (increased symptoms at the time of the trauma that remain chronically elevated); and delayed (disruption steadily increases over time and remains elevated).1 The most common patterns are resilience and recovery.1 Children who experience personal loss and/or greater disruption and those who perceive life threat in the context of the trauma are more likely to follow a chronic or recovering trajectory, rather than one of resilience.2

Posttraumatic Reactions

Whereas common acute disaster reactions could be viewed as psychiatric symptoms, many of these can be considered normal reactions to abnormal situations.3 Persistent symptoms can become maladaptive. Studies have measured various negative psychological outcomes in children after a mass trauma. Adolescents may have difficulty accurately understanding the limits of their control over aspects of the event.4 They may feel guilty, overly responsible, and/or immune to danger, and they may even idealize aspects of the event or perceived solutions.4 School-age children may develop an obsession with trauma details; become withdrawn, hypervigilant, fearful, irritable, and/or angry; and/or experience attention problems, sleep disturbance, and/or somatic complaints.4,5 Young children may become more “clingy” or afraid to separate from caregivers, and they may develop regressive behaviors, sleep problems, and/or aggression.4,5 Relative to older children and adults, young children have an added challenge of relying on caregivers to report their distress due to their lack of self-awareness and communication skills; they are likely to have more difficulty identifying, expressing, and understanding their distress, thus the extant research may underestimate distress in young children.3,5,6

Acute Stress Disorder and Posttraumatic Stress Disorder

Acute stress disorder (ASD) and posttraumatic stress disorder (PTSD) differ mainly by the timing and persistence of symptoms. A diagnosis of ASD can be made when posttraumatic stress (PTS) symptoms present within the first month after the event and last from 2 days to 1 month.7 In addition, dissociative symptoms, such as feeling detached or numb, are more prominent in ASD.3,7 ASD is believed to be the most common psychiatric disorder after a mass trauma.4 However, research on ASD is limited because the early onset and short course of the disorder make it difficult to organize and initiate studies.3

Prevalence of diagnosable PTSD in children after a mass trauma varies widely, with studies finding rates anywhere from 1% to 60% of a sample.8 PTSD symptoms are commonly elevated in children in the first few months after a disaster but commonly decrease within the first year, with full recovery within the first year for many.1 Only a minority of children develop chronic PTS symptoms—rarely over 30% of a sample1—whereas acute PTS symptoms may occur in close to 50% of a sample.9

Depression and Anxiety

Mass trauma is associated with elevated depression and anxiety in children, which are often comorbid with PTSD1 but may have a later onset.10 Depression is especially common among those who have lost a loved one, witnessed injury or death, or experienced fear or injury during a disaster; those who have poor social support; and those with previous trauma exposure.11 Although studies of postdisaster anxiety disorders are limited,8 anxiety symptoms are common across age groups after a disaster.1,3,8 In adolescents and older children, anxiety may present as generalized anxiety,1 fear,3 or social anxiety.10 Anxiety in young children may present with symptoms of separation anxiety disorder.3

Grief

Grief and bereavement as postdisaster outcomes are often comorbid with other conditions and are infrequently studied independently of PTSD, depression, or anxiety.3 Many symptoms of bereavement and comorbid disorders overlap, compound, or complicate each other.3 Traumatic grief involves the combination of bereavement and trauma symptomology associated with the loss12 in which PTSD symptoms from the loss interfere with the grieving process.3

Behavior and Substance Use

A meta-analysis study on youth postdisaster found a positive association between disaster exposure and externalizing symptoms.10 For example, children may become aggressive, disruptive, and/or delinquent.5,10 In addition, adolescents may become oppositional and/or engage in high-risk behaviors such as substance abuse.5 As a negative outcome of mass trauma exposure, substance use in adolescents may lead to substance dependence and/or abuse and other adverse physical, psychosocial, and educational effects.13 Vulnerability factors for substance use postdisaster include close proximity to the event; exposure to previous trauma; and at least in some societies, racial/ethnic minority status.13 Family factors (eg, parent support, parent supervision) and neighborhood and school characteristics also influence substance use behaviors in the context of disasters.13

Posttraumatic Growth

Although relatively unexplored as an outcome of PTS in children, posttraumatic growth (PTG) constitutes another potential outcome.14 PTG refers to growth or strengthening of self, beyond that which existed prior to the event, as a result of struggling with traumatic exposure.14 PTS and PTG are not exclusive of one another.15 The cognitive struggle to make sense of or find meaning in a traumatic event through, for example, internalization or rumination, is believed to be part of the process of PTG.14,15 A systematic review of PTG studies in children identified five domains in which PTG is often recognized: new possibilities, relating to others, personal strength, appreciation of life, and spiritual change.15 Although the majority of children who experience PTS recover or return to pre-event functioning, the prevalence of PTG in children is currently unknown.

Factors Influencing Outcomes

Predisaster Child Characteristics and Family and Social Context

Demographics. Although the extant research is mixed, the consensus seems to be that girls report more PTSD symptoms than boys.1,3 Other symptoms may vary with, for example, boys showing more externalizing symptoms than girls.12 Girls and boys may interpret or report experiences and responses differently;16 for example, in some cultures, boys may face greater stigma if their distress is known.17 Studies of the relationship between age and severity of posttraumatic consequences are inconclusive1 and reveal a number of mediating factors, such as how children make sense of their experiences at different developmental stages and the level of influence a parent has on the child's perception of danger or safety.16 Children of racial and ethnic minority groups in the US tend to report higher levels of PTSD symptoms that are also more prolonged, but these associations may be compounded by socioeconomic factors.9

Child personality and experiences. Data on predisaster functioning are rarely available for comparison, making it difficult to accurately study the impact of predisaster functioning on postdisaster outcomes.3 Although retrospective reporting of predisaster functioning may lack objectivity, correlations have been found between predisaster anxiety and postdisaster PTSD, and between predisaster depression and stress reactions after a natural disaster.3

The question of whether previous trauma operates in a protective capacity (inoculation) or increases risk for negative outcomes of subsequent traumas (sensitization) is not well understood.3,17 The theory of inoculation poses that if a person has experienced a traumatic event previously and has the time and capacity to find resolution, the previous trauma may support mastery, self-efficacy, and resilience.3 Alternately, if the previous trauma overwhelmed the child's capacity to adapt and if they have not had the time or resources to recover, the result can be increased vulnerability due to cumulative stress.17

Disaster Event

Disaster typology. Both the type (eg, natural, manmade, technologic) and characteristics (eg, location of event, number of casualties) of the disaster have been examined in association with disaster outcomes.18,19 A meta-analysis of child disaster studies found comparable effects for natural and man-made events.18 Various characteristics of the disaster are likely more determinative of outcome than the type of the disaster. For example, disasters in developing countries appear to generate more severe impairment than those in the US or other developed countries.19 The number of disaster deaths contribute to PTS in children exposed to disasters.18

Exposure. Exposure is a central determinant of disaster outcome. Exposure can be measured in terms of geographic proximity, relationships to people who are directly exposed, initial subjective reaction,18 and the amount or frequency of media contact.17 A meta-analysis of child disaster studies examining PTS outcomes found significant effects for physical proximity, perceived threat at the time of the disaster, general distress at the time of the disaster, and loss of a loved one or friend.18 A recent meta-analysis found significant media effects for PTS in children and adults exposed to mass trauma.20

Posttraumatic/Recovery Environment

Disruption. Disaster-related life disruption, such as displacement from home or school, separation from family or friends, disrupted schedules, missed social or recreational activities, and changes in family finances can be long-lasting stressors that contribute to adverse outcomes in children exposed to disasters.3

Family complications. Family conflict and violence, substance use, divorce, marriage, and birth all tend to increase after a disaster1,3 and may complicate disaster recovery for children.1 In addition, overall family stress and parental burden tend to be elevated after a disaster, which may be especially critical in families with preexisting chronic stress, vulnerability, and/or cumulative trauma.1

Family support. The importance of parental warmth, attunement, and availability in children's disaster recovery cannot be overstated.6,17 Positive parent-child relationships seem to reduce the risk of PTS, anxiety, and depression.21 The quality of the parent-child relationship and the child's perception of relational safety are predictors of resilience.17 For example, child perceptions of strong attachment, trust, open communication, parental acceptance, and parental control prior to Hurricane Katrina were associated with lower levels of anxiety postevent.22

Parent reaction to a traumatic event is one of the strongest predictors of children's reactions3,6 especially in young children, as the child's perception of a traumatic event is largely filtered through the caregiver's perspective.4 If children perceive parental distress, they may attempt to hide their own reactions and concerns to avoid further upsetting their caregivers.5 Due to their own distress and their focus on other issues, parents may underestimate or inadvertently overlook their child's distress or falsely assume the child does not need additional support or reassurance.3 Alternately, overprotective caregiving may undermine children's resilience, self-confidence, and self-efficacy.17

Social support. Social support is a widely recognized protective factor contributing to reduced depression, anxiety, and PTSD symptoms, as well as improved adaptive capacities in children exposed to mass trauma.3,21 Schools are especially important to the recovery of youth, as they are a site for connection, nurturance, play, learning, routine, and both giving and receiving peer support.17,21 Social support derived through the school environment can be especially important when parents are overwhelmed or emotionally unavailable.17

Implications for Intervention

Interventions have been developed and evaluated for delivery across disaster phases from pre-event to the early postevent period and throughout recovery months to years later.23 Disaster services are offered in various locations including within existing service systems (eg, health and mental health care facilities) and child social and educational systems as well as in disaster-specific settings (eg, shelters).23 The choice of intervention setting depends on aspects of the disaster and of the children receiving the intervention, on the type and goals of the interventions being delivered, and on the availability of providers.23 Schools are a preferred venue for delivering interventions because children are accessible24 and the stigma associated with mental illness is reduced.25 Teachers and trained paraprofessionals may deliver interventions focused on wellness, resilience, and coping in community settings such as schools while clinicians are needed for interventions delivered to children with clinical conditions.23,25 All providers are likely to need training in specific issues associated with disaster mental health services.23

Intervention Components and Intervention Effectiveness

Some child disaster interventions use a single intervention approach and some use multiple techniques packaged for delivery including a combination of psychoeducation, cognitive-behavioral, exposure, trauma narrative, relaxation, eye movement desensitization and reprocessing, stress management and stress reduction, coping, and/or grief and traumatic grief components.5,23,25 Meta-analyses of child disaster intervention studies have found small26 or medium27,28 overall effects on PTS outcomes, from no overall effect26,29 to a small-to-medium27 overall effect for depression, and no overall effect for anxiety.26,29 Cognitive-behavioral approaches have been widely studied,25 but there is insufficient evidence to declare one approach more effective than others.25

Clinical Treatment

Clinical interventions, which should be based on ongoing assessment, may be necessary for some children, especially those who experience disaster-related bereavement23 and those with vulnerability indicators such as preexisting conditions and exposure to prior trauma,24 as well as those who are directly exposed. Clinical treatment should support natural recovery and coping, minimize arousal, address comorbid conditions, and reinforce natural supports.24 Children should be treated within the context of the family when possible.24 Group interventions may be used to educate children and their parents; to promote sharing, trauma processing, and coping; and to identify children in need of individual attention.24 Group work, which can create distress in some children, should limit participation to children with similar experiences.24 Psychopharmacologic interventions are reserved for use as an adjunct to other interventions if needed for severe reactions and comorbid conditions.24

Conclusion

Although most children demonstrate resilience or recovery from the stress of mass trauma, some are at risk for adverse outcomes, including ASD, PTSD, depression, anxiety, grief, and/or behavior problems. Prevalence varies widely based on a child's exposure, preexisting characteristics and experiences, available resources, and supportive relationships; these variables should be considered in public and mental health risk assessment after a mass trauma. Choice of intervention should be guided by consideration of children's exposure and reactions, timing of the intervention administration, and delivery setting and providers.

References

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Authors

Grace L. Whaley, LMSW, is an Instructor, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center. Vandana Varma, MD, is a Child and Adolescent Psychiatrist, Department of Psychiatry and Behavioral Health, HOPE Community Health Center. Erin M. Hawks, PhD, is an Assistant Professor, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center. Robyn Cowperthwaite, MD, is an Assistant Professor and the Chief of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center. Lenore Arlee, LCSW, is a Clinical Instructor, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center. Betty Pfefferbaum, MD, JD, is a George Lynn Cross Research Professor Emeritus, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center.

Address correspondence to Grace L. Whaley, LMSW, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, 920 Stanton L. Young Boulevard, Oklahoma City, OK 73104; email: Grace-Whaley@ouhsc.edu.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20200812-02

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